Tag Archives: bone marrow transplant

It is strange to sit in my cushy arm-chair, to wake each morning while three others sleep and watch light overtake the earth, sun rising over curvature and bathing the evergreens in bright liquid green, the underbellies of clouds turning pink, the grasslands of the valley warming in yellows. The aspens here are still leafless, but the snow now stands only in shady patches on the hills, amongst the trees. Yesterday morning spring snow flurries filled the landscape with the swirl of bright white flakes against greening fields, the day warmed and the sky turned blue.

It feels so good, so utterly right to be home. I feel a fool that we never even thought to include Allistaire in our decision-making about hospice, where she would end her days. Then again, while I had considered on many occasions where I would want her to die, the truth is, the word “hospice,” absolutely knocked the wind out of me when it was first voiced last Thursday. Hospice has always been linked with horror, the most inconceivable sorrow, the worst possible outcome. It is a word to turn from and flee from, willing your legs to run at speeds you didn’t think was possible. All you want to do is to get away from it. And as I have over the years been witness, sometimes from afar, sometimes closer in, to the end for many children, some going home, some dying in the hospital, I have asked myself, what would we do were it Allistaire?

Everything about the last four and half years has been held up against the question of, “what is best for Allistaire?” All choices have been formed in accordance with the goal of providing her with the best possible care. As I had considered those who went home and those who remained in the hospital until the end, I thought, oh, but I want so badly for those that care for my sweet girl’s body in her last days to know her as more than a body, to know the spunk and giggle of the girl whose body is betraying her. I want to scream at the thought of her being viewed as only a heart rate, number of respirations, kidney function numbers, a pain plan. No. NO! This is Allistaire Kieron Anderson, the child of my flesh, a girl hilarious and witty and beautiful and so very tender and kind of heart, a girl who will always entice you to play, who loves dress-up and colors rainbows endlessly. It is this bright being, this girl who I so desperately longed to know as a woman, a girl who has fought so much harder than you can ever imagine, who has endured so much – she is to be handled with the greatest of care, with reverence, with delight and love. And so I thought, I would keep her here, in this land where no only can she receive the absolute best of medical care with expertise in children, but with those who have cherished her, who have laughed with her, who have watched her grow up. These are the people who in whom I will entrust her last days.

But somehow, it just never occurred to me that such a question might really matter to Allistaire herself and that there could be things even more precious than having those who care for her, know her. So when we told her that she would die and asked if there was anything she really wanted, and her words came quick and clear, “I want to go home,” there was to be no denying her that wish. And we scrambled to make that happen, and the honest truth is that I called out pediatrician in Bozeman to let her know we were coming home for a visit, primarily because if Allistaire died at home I needed Dr. Ostrowski’s help to know what to do. Before I knew it, and without intending to, we had a “travel contract,” set up with Hospice of Bozeman. And as we stood in the airport Saturday night with the sun going down over the Olympic Mountains, the land of my childhood, the thought of going home began to swell in my heart. I knew that the setting of that day might be Allistaire’s last in the land of her birth, and yet home was calling in the deeps of me.

In the dark of night, the plane flew east, moonlight making the snow glow blue over endless mountains, the depth of the Cascades shocking in contrast with our perception of them from Seattle as simply a line across the eastern horizon. On and on we flew, the mountains never seeming to let up. The further east, the more my longing grew and in crept the thought, “I don’t want to go back.” The urgency, the clarity of that desire turned more and more to resolve, the ambiguity of it transforming into solid matter. I want to be home. And why? Why would we take her away from home again? My rational brain spoke up telling me again how we didn’t know how well she could be cared for in Bozeman and Seattle was a land of plenty when it comes to medical care. And while I conceded to that voice, still my heart claimed home. And as I allowed my heart room to speak, again it became clear, how, how could we force her again to leave her home, a little girl who has hardly known home, who has been deprived of it, always being forced to buck-up and do the hard thing because the hard thing has been required to give her the best chance of survival. But now? Now? Was Seattle really the only place that could provide her what she needed to keep her comfortable or could we perhaps find a way at home.

There are literally countless people who have been incredible gifts to us in this long, trying journey. And really, I think I’m tired of hearing people say “Cancer Sucks.” With all my heart I wish Allistaire could have had the chance at a thriving life, but cancer, this wild, rogue cell of unfathomable complexity, in truth, I am in awe of it, it is a fearsome wonder that causes the humbling of the most mighty, the most intelligent, the most tenacious. And cancer ushered us into a world we could have never chosen, a brutal road with hardships that have stripped us of so much, has gutted us and left us ragged and bleeding. But along this very path I have at last been given eyes to see things I was previously blind to, and my wounded heart has been given entry into fellowship with those who also suffer and its longings have shifted. This path we are told to fear, we are told to avoid at all costs and which really has stolen so much, has also had treasures scattered that can only be found here. And it has been along this road that we have had the delight of having our lives being entwined with phenomenal people.

Dr. Angie Ostrowski has been one of many such folk and it is in large part because of her willingness to go above and beyond the requirements of her role as our pediatrician, that we can have the confidence and peace of having Allistaire remain at home. Dr. Ostrowski came up to our home on Sunday afternoon and looked over Allistaire, a girl she has cared for the past four years, through two relapses and post bone marrow transplant. She talked with Sten and I about our desires for Allistaire and how she along with hospice here in Bozeman and with Seattle ever available for consult, might be able to meet these needs and desires. And while I suppose I already knew this to be true, I was reminded that even here at home, we have been blessed with excellent medical care, and more, a doctor who has known and loved my girl.

Sten and I both want what is best for Allistaire and ultimately long to care for her little self, the girl even more than the body in which she dwells. For Sten there has been some concern about the potential difficulty of having Allistaire die in our home, and the impact of that memory for all of us going forward, however, in a commitment making a way for fulfilling as many of Allistaire’s desires as possible, we agreed to ask Allistaire whether she wanted to stay at home or go back to Seattle. Originally our plan had been to draw labs on Monday and depending on how rapidly she seemed to be declining, we would decide whether or not to go back to Seattle. But now, as we crouched before her sitting on the couch, and Sten asked if she wanted to stay or go back, again her words came without hesitation, as natural as breathing, “I want to stay home.” And with that, it was decided that will not be going back to Seattle, and the absurdity of every asking her to leave home again was validated. Why? Why thrust this girl yet again from home?

And home, home, is not the very word calming, settling, restful? Some think that we ought to cut our own days short when we see the likelihood of suffering coming for us. I can only ask, what treasures, what sacred gifts might we be denying ourselves if we forego these last days? Solveig and Allistaire sat snuggled up on the couch yesterday morning, holding hands and Solver’s arm around Allistaire, she nose sometimes nuzzling Allistaire’s bulgy cheek, Allistaire’s blue eyes looking out at valley and mountain and field. Solveig reading story books to Allistaire while later she slept. The two of them up in Solveig’s loft working on a craft. Allistaire sitting with Uncle Peder, him teasing her, and her wry sense of humor jousting back. Solveig, cousin Per and I clustered around the Candy Land board and later sitting out on the deck encircled around the little fire, roasting our marshmallows with Aunt Jo, perfecting s’mores and the challenge of just the right degree of toasting to pull of the crusty outer layer, the “scab,” and place it again over the glowing coals, the sound of wind chimes and deer in the field. Solveig and Haaken and Per running down the driveway, flying the dragon kite with Allistaire tucked under blankets sitting enthroned in the cozy chair we set out in the grass. Friends coming by with boxes of Kleenex and tasty food and love and a commitment to continue on as friends, never turning away when there are no words that can ease the pain. Family flying and family driving from Washington all to gather round this amazing girl we have loved so passionately. Home. Where else could we possible want to be. It feels so utterly right to be here, some satiation settling into the weary cracks of my bones.

Sometimes she sleeps when everyone is gathered round and talking and her body simply needs to rest all cozy on the couch. And her tenacity remains as she insists on walking when it seems it could only hurt. And somehow, the “Buddha Baby” look of being fluid over loaded, presumably from kidneys waning, has dissipated some so that her eyelids no longer seemed strained though her belly is still rotund and pulling her shirts tight, disappointing her that she could not comfortably fit into her mermaid costume. And oddly her labs looked better overall yesterday, her creatinine down from .8 on Saturday to .52. Her liver function numbers the same, her potassium and uric acid actually down and her GFR (rate of kidney filtration) improved. Her platelet count and hematocrit still far enough above her transfusion thresholds that she should be fine for at least a few more days before another possible transfusion. Her ANC is down a bit for sure and her LDH (and indication of cell turn over) rose substantially. Thankfully her pain is under control. While we have to handle her very gently given the pain movement causes her, at this time she is only on the extended release morphine tablets and hasn’t required anything additional. She is sleeping peacefully at night and during her day-time naps.

It’s crazy how I still hold out hope, how I still think somehow this can turn around. I guess the reality is she’s been in such desperate spots before, dark places with no seeming exit and against all odds, on quite a number of occasions she has made it out, overcome what seemed impossible. The peaces comes quick when I am reminded that either God miraculously cures her or she dies. Seems funny that this should bring peace but it does, because I have yielded this girl, handed her over to my Father and there is peace in no more wrestling, no more wondering. Either way we are at home to stay. We are never going back to Seattle to battle cancer.

We are thankful for the days given us, the hours, the nights that turn to morning. It is perhaps the strangest of all to feel and know that we are eternal beings that making our dwelling for now in temporal homes, in vapors, as grasses and flowers that are here for but a moment and then wither and die and yet yearn for what we were meant for, a life that goes on.

Thank you to so many who have poured out your love and compassion on our family, for your passionate prayers, for your words when you feel your words fall flat and are insufficient, for your sweet faces and texts and cards. Thank you to so many of you who have donated money to accelerate cancer research at Fred Hutchinson Cancer Research Center. While I have respect for our devious foe, cancer, don’t get me wrong, I still intend to pursue that beast until it is slain and I greatly appreciate your support in this endeavor! So below is a link to donate to Obliteride, and also a link for Bozeman folk who’ve expressed a desire to help us out with meals.

I should also note, we are not planning to have any sort of memorial service right away. I do not want my time divided right now, I want to cherish these days. There will be time later to plan how we want to mourn together and rejoice in her sweet life together. However, knowing that such a time will come, it would be such a gift to us if you would send us a wee note of what you have loved about Allistaire, how her life and story may have had an impact in yours. I will never forget the clarity of God’s words to me that gray December morning in 2011 and the peace that they wove in my heart – “Do not focus on all that you fear you will lose, but be expectant, be on the look out for what I will do, for the bounty I will bring out of this.” While my hope for that bounty lies largely in heaven, it would bring such humbled joy to get a glimpse of God’s goodness here and now, in this world in this life. So if you’d be willing to take the time, mail your notes to our address below:

The cursor blinks. Waiting. Waiting for the words to come, to extract from the blur, to distill the thunder and wailing silence.

We are those people. We have become strangers from even those who have known this road with us most intimately. She is not yet gone but the memories, they flash in and burn. Every step igniting shards of pain. Beauty and joy, that with the awareness of their loss, pierces rather than delights. Thoughts, uninvited barrage, come sailing past, slicing, blunt force. I was teaching her the names of plants and she would yell out their names as we drove about – forsythia, I see forsythia, she exclaims. Red-tip Photinia gets blurted out over and over. And there it is, a brutal mingling of what once brought joy and proclaimed life and growth is transferred into the category of no more and then the gaping expanse of emptiness where more names of plants were supposed to dwell. But I wanted to teach her to crouch low and delight in the delicacies of moss, of tender fern, of trickling stream, to watch the light stream through trees, to stop and listen, to soak in life, to learn the secret of the bounty observation brings…

We have had rough times before, really really rough times. There have distinct situations in which her life could have easily veered toward death, it was right there, standing at the threshold but never had it entered in. To look at her is disorienting, to consider the severity of the situation keeps getting rejected and spit out over and over. Dr. Cooper called in early evening. I told him of the second guessing our decision that had already come, of the disbelief that she really is being over taken by her cancer, that there really is nothing to stop it this time. I ask him again, are you sure, totally sure there is nothing for her, nothing? Nothing. There is nothing left.

This morning I thought, maybe there is something out there in the world, some new and wild way to tackle her beast, some new angle that can catch it unawares and strangle it at long last, extinguishing its mindless assault. But no. There are only the same grooved paths. Therapy, primarily chemo, all to get to a transplant and she just had a transplant. She just had THE transplant, the no holds-bar transplant, a full-conditioning volley of weaponry – if that didn’t work, there is at present nothing more under the sun that can cure. And so the question rises, can we give her something to hold her, to simply keep her going? But to what end? And it’s not like this doesn’t come at its own cost. The one possible goal was a CD123 CAR T-cell trial that is still in the works at CHOP (Children’s Hospital of Philadelphia), but it is months and months out. And with Allistaire’s current heart function she wouldn’t qualify anyway. And perhaps more than anything, the startling speed of this cancer’s progression makes nearly any novel therapy too late. Her kidneys are suffering with a steadily rising creatinine level. Her potassium and uric acid or rising due to tumor lysis. And this rise in potassium, the unbalancing of electrolytes, could at any moment cause cardiac arrest.

Before we knew it, without intending to and without being able to yet utter the words out loud, we began to discuss what it will look like for her to die. Does kidney failure hurt? No, it would be peaceful. As would her heart simply stopping, peaceful. What a strange thing to hope for your child. I do not want chloromas to overtake her body – they cause incredible pain and deformity. No, it seems most compassionate to make way for some other finality. I do not want her to bleed out. We must keep giving her platelets. But red blood? It may come to the point that we simply don’t give her any more red blood and she will grow more and more tired and sleep and never wake up.

I cannot believe I am having to have this discussion. I cannot believe the words entering my ears or coming from my tongue. It sounds like logistics, some planning committee. Hospice will meet you on Monday at noon. PAC Team (Pediatric Advanced Care Team) will do this, Dr. Cooper will check on this…but there is this little girl, the nucleus of all these efforts, these considerations. And while it all might sound callous and aloof, distant, I am confident of the sincere care for Allistaire in that room, especially that of Dr. Cooper and Dr. Bleakley, two doctors who have intimately walked this road with us, who have thought long and hard over Allistaire. They are dear to me and I trust them. I trust them because the are incredible brilliant people who have walked this road with families for many years, who understand the disease far, far more than most and who have known Allistaire as a real girl, not a med rec number, not a PET scan result or Flow Cytometry percentage. And so with what very little time we have left with our girl, I will not go running after obscure options. We have chosen to rest in the expertise of our doctors who are connected nationally and internationally with fellow physicians also working on AML. They are a gift of great worth to us. They honor us and honor Allistaire in their enduring work to care for children with cancer.

I am already incredibly tired. I don’t want to leave her side. I feel the tiny bones in her hands and the light passing across the tiny little peach-fuzz hairs on her cheeks, the long dark lashes and puffy eyelids. I listen to her breathing and rub the warmth of her back, the delicate blades of bone. And it all just hurts so bad. Tonight is Friday night. It’s always been Friday night pizza night and a movie. Sten and Solveig honor that tradition in Montana and we here in Seattle. But tonight? What is tonight? Is it my last Friday night with Allistaire? I gag at the thought. I long to throw up, to some how clamp my hands over my ears, to press my eyes closed tight and somehow make it all go away. Can I just go back to a week ago? Can I just undo this awful week? Can we please not take this path? I want to scream and scream and scream until my voice is gone.

When we sat with Allistaire on her bed and told her that we had met with the doctors and there was no medicine left, that she would die, we asked if there was anything she wanted to do. “I want to go home,” she said. And while we feel our resources for this situation are best here, we are taking her home for two days. Two last days at home in Montana. Time for the four of us to dwell in that home one last time altogether. Time for our family to gather. I don’t know how our hearts will bear up under it. But we must live out each moment, each minute that amasses to become an hour, and hours days. Yet we may really be down to days and I can’t stand the thought of it. My body just shakes, rejecting that the child I gave life to I have to at last lay down and walk away from.

I must go to sleep. In the morning I will pack for this brief visit home and she will get a transfusion of platelets and red blood to tide her over.

Thank you for your many messages of sorrow and love. Thank you for your prayers. Many of you have expressed a desire to help. First please understand that our time with Allistaire is so short, we will really be keeping to ourselves and our immediate family, a few close friends. At this point in time we ask that you don’t ask to come visit unless we have already communicated with you. Please know this is no reflection on you, rather a need to be realistic with our finite time and emotional resource.

Another way to demonstrate your angst toward cancer, your sorrow over the loss of Allistaire’s fiesty bright sweet spirit in this world, your support of our family, is to give to OBLITERIDE. I cannot tell you how brutal it was this morning to hear of amazing research underway in the lab that is no where near being ready for Allistaire. While I rejoice at the advance of cancer research, it is too wickedly slow! What heartbreak to know that while cures are underway, Allistaire’s body will have already ceased. Please consider honoring Allistaire’s life by supporting me in funding cancer research at Fred Hutchinson Cancer Research Center through Obliteride.

“Humble yourselves, therefore, under God’s mighty hand, that he may lift you up in due time. Cast all your anxiety on him because he cares for you.

Be alert and of sober mind. Your enemy the devil prowls around like a roaring lion looking for someone to devour. Resist him, standing firm in the faith, because you know that the family of believers throughout the world is undergoing the same kind of sufferings.

And the God of all grace, who called you to his eternal glory in Christ, after you have suffered a little while, will himself restore you and make you strong, firm and steadfast. To him be the power for ever and ever. Amen.” (1 Peter 5:8-11)

I was watching a movie…a man trudging through the snow, days and days, months of journeying, comes to the top of a ridge. Out before him unfolds an expanse of evergreen covered hills and mountains with snow, clouds settled in the low lands like a thin veil of blue. Everything in my heart heaved one groaned word, “home.” Oh the longing to go home, it pulls deep. The longing to at long last lay down the battle, to be at rest, to no longer strain, to be in the presence of those who love you, to feel safe, to cease the striving, to release, for all to be as it should be.

I hardly knew it was Easter. I mean the stores made it clear that it was somewhere on the horizon, but suddenly it was upon me, Sunday was coming. And I push aside all the eggs and the bunnies and candy and chicks like so much underbrush, hacking with machete to get where I’m going, to get home. To find rest. How timely that it is Easter for I am in ever so much need of rest. I weary. My heart faints. My face throbs from pain at the relentless tears. My voice feeble, oh Father how I long, long to curl up beside you, to have your mighty arm encircle me. I long for you, for that rest that Easter makes possible. And you stretch out your hand to me and invite me into that rest now. Come now, enter in, abide in Me as I abide in you.

We are in the garden and the serpent seeks to whisper disbelief, to suggest You Father are not really so good, are not really so kind, but cruel, a depriver of what I really need. And I see you there my Jesus, agonizing over what the Father has asked of You, asking if there be another way, oh let this cup pass, let it pass God! And when the answer comes, that No, No this is the only way, You yield. You say Yes to the Father and you lay down Your life. Your greatest work was to rest, rest in the Father, yield to Him.

Oh Christ, our great High Priest, our compassionate intercessor, hold up my heart. Enable me by your Spirit to yield, to yield, to say Yes Lord, Yes, You are good and I will trust in You, I will rest in Your holiness. I will take Your hand and follow wherever You will lead, even if into blackest of night. I lay down my life and it truly feels as if my lifeblood flows out. I am faint, so weak. But will I love as You have loved? Will I lay down my life, my vision for what my days on this earth were to look like, will I say Yes to whatever you deem best to love others? Oh Father, you see them, you see those dear to me there…across the cavern, I hear their voices as though muddled through water or glass, I reach out but they are too far, so, so far. Will I say Yes Lord, she is Yours, and Yours to take? Am I willing to cross over into that dark, into that wilderness, that wasteland? I have always known this, the stark truth of it always, always looming in the periphery…You call some of Your children to go all the way down that dark road. You draw them into the black. Because only there can You demonstrate, not in word, but in reality, that I will find You in that darkness and You are the God that turns darkness into light.

Lord, I am far too small to say what is right, what is best. I know only that my whole heart longs for You. And I do say Yes to You, I will take Your hand and walk into the black because ultimately I do not despair. I know what happened, what we remember on Easter, I know You said Yes to the Father, You yielded to the Father and You were crucified for it. You were put to death and swallowed into the black. And yet, You rose, You overcame the power of sin and death and the tomb was empty and everything about those three days has everything to do with this day, and all the brutal days behind and the ones to come.

Hear my cry to You oh my God! Many recoil at this faith they find so absurd, so utterly foolish, so offensive. I know only that I love You my God. I have tasted of You and I can never walk away. Hold me tight. Gouge out my heart if You must, but Spirit, teach me the truth of these words of Jesus, “If any man will come after me, let him deny himself, and take up his cross, and follow me. For whosoever will save his life shall lose it; and whosoever will lose his life for my sake shall find it.” You are my hope, my home. You are my resting place, my Sabbath rest. It is only in You and through You that I have life and all will be made right. It is only because of You I have any hope of a gentle and quiet spirit, a spirit gentle and kind because I have been forgiven so much and a spirit quiet because in You it is finished, You sit at the Father’s right hand. All Your promises are Yes, and Your will be done on earth as it is in heaven.

I thought this afternoon I would sit down to write of nine tests showing no evidence of cancer in Allistaire, for in all nine I had word that every attempt to find her leukemia came up with nothing. A brain MRI, a PET/CT, a LP (Lumbar Puncture), ultrasound, peripheral blood chimerism and whole marrow chimerism, flow cytometry, pathology and cytogenetics – one by one the results trickled in over the course of a week. I would not claim victory until every last one came through. And even then, when my sister-in-law asked me if I was excited, I said No. No. We have had clear results before and the cancer has always been there, ever lurking, ever seeking to devour and destroy. I am thankful, of course. I am glad. I can breathe a bit easier, but at any moment, any moment, it could all change again.

I had hoped this transplant would at least give Allistaire time. Time. Time for what? Time for research to catch up with the complexity of these cancer cells that seem ever able to evade, time to design a full-proof weapon, time to make it down the road far enough for some new therapy to intervene before she be swallowed alive by this beast. I had started to dare look down the road, to think about the actual possibility of going home. Maybe she would be alright. Maybe it would actually make sense that I was teaching her to read. Maybe she would live long enough for literacy to matter. She said in the car this morning on the way to clinic, “I wonder if I’ll have babies.” Pain squeezed around my heart. “You probably won’t be able to have babies, sweet girl.” “Why not?” came the sweet voice from the back of the car. “The part of you that makes babies was too badly hurt by your chemo. But you could probably adopt babies.” Her face lit up. She liked the idea of that. And I told her, that if she lived long enough to be old enough to be a mom, that would be amazing enough, she would probably be okay with not being able to grow babies in her own body.

Our schedule only required we come in for her second set of labs for the week. We sat on the bench just beyond the elevators there on the 6th Floor at SCCA, the Bone Marrow Transplant floor. We had checked in and were settling into the wait and to begin our breakfast when Erin the P.A. said that Dr. Burrows wanted to talk to me about her PET/CT results. Instant panic. Instant terror, a swallowing, the world turning black, cold down the neck, drowning, it’s coming, it’s coming, I know what’s coming, I’m going down and like that every hope was snapped off like a dry twig.

We were taken to the conference room and I handed Allistaire my phone with the sound turned off, and she turned to Toca Boca Hair Salon and proceeded to spray the girl’s hair pink and purple and green. And Dr. Burrows came in and looked at my face and asked how I was and I stood there with a great blade struck through my torso, the blood already staining my shirt and the beads of sweat on my forehead and the color gone from my face. And she went onto explain that the while the brain MRI had originally been read as everything being clear, because the PET/CT showed an area of FDG brightness of 4.0 (normal being 3.0 or lower) in the exact area that her chloromas had been, this prompted a second group review of her past and present scans. In short, there are changes in the tissues in her right sinuses, changes that may be because of her significant cold, due to the human metapneumovirus which has yielded phenomenal amounts of snot for the past month, or it could be disease. It could be leukemia. There is no definitive way to tell at this point. We’ll have to rescan in a month. We’ll look again when her cold has cleared and the tissues in her sinuses have had time to return to normal if it really is only the impact of this virus.

Yesterday I woke several times in the night. Ava. Ava. Ava was always there. Immediately. Her name was the first thought formed, resounding, pounding. Then next there was Esther, her mom, my friend, my sister in Christ. Esther. My friend flailing in the water, struggling to catch her breath as the relentless waves threaten to swamp her. And we’ve been texting and she tells me it looks like the tumors are coming back and she cries out into the black, looking for a way through the thick dark, looking for a ray of light to get her daughter through to the other side of this cancer, this ravager of her flesh. And I have no life line for Ava’s flesh and I pray to God that He would work through Dr. Cooper. But to Esther I speak our Father’s promises, I ask His Spirit to speak His words of encouragement, of peace, courage my sister, courage! The very same power that the Spirit exerted to raise Christ from the dead is at work in us! If even the worst comes to us, our Father will carry us, bind up our wounds.

It is strange to dwell in two worlds, to have your heart so firmly planted in both, the temporal and the eternal. We’re sitting on the $40 Ikea rug putting together her Elves Lego set she got for her birthday. I love to watch Allistaire’s face. To catch the light skimming across the delicate peach fuzz of her deliciously adorable cheek, the perfect little swoop of her nose, her long thick lashes growing back in, the delight in her eyes as she tells me a story, the movement of her lips with voice just so sweet. I watch her two small hands struggle to get the Lego pieces to fit together just right. To know her is to know a hundred-thousand million delights. The thought of losing her, of having her absence an ever-present ache and sting, oh how can we bear up under such sorrow? How can some stupid little cells take that all away? Is there really, really nothing we can do to get rid of them? I think of the life we could have had. Six years old and what has her life looked like? And who might she be in the world if she just had a chance to live?

Today is Good Friday, a name that still doesn’t sit right. I don’t know what would be a better name, maybe Brutal, Wretched, Agonizing Friday? I can’t stand it when people try to comfort me and brush aside all the pain and the sorrow and focus only on the good. I know they’re just trying to help, desperate to alleviate some of the sadness. But this is real. This is not a movie. This is not a story. This is my child. This is my life. This is my flesh bleeding out. And I actually have to live every day looking at my beautiful child’s face knowing tumors may be growing even now, to one day deform and strangle and leave a gaping, ragged hole in my life. And Christ really did die an agonizing death on a cross because I really have sinned, sinned long and sinned hideously and shaken my little fist at God so many times, spitting on His name. Those ten commandments – I’ve broken every single one. And I don’t even have to look out in the world, to Belgium or Trump or some slum in India with little children begging for food, to know just how broken this world is. I live it everyday in my impatience and arrogance, my selfishness and covetousness, my anger and laziness. I live it everyday as I scan the details of Allistaire’s labs, and MRI reports and research abstracts and Facebook posts about another friend’s child whose tumors are spreading and he’s losing control of his limbs and his body that was headed toward manhood is growing weaker and weaker.

Good Friday? It is only good because we know what happened on Sunday and Sunday could never be had we not first lived through Friday. Easter has everything to do with cancer and it has everything to do with my weariness over having to ask Allistaire for forgiveness again because I tore into her with my words and did not treat her with gentleness and patience. I wake up from a restless night, neck and shoulders aching, still tired. And the memory of all the sorrows that I laid down with at night come slamming back into my consciousness with the weak morning light. But it’s Good Friday and I know because of what happened on that hillside in Jerusalem a few thousand years ago that is not just a story, that His mercies are new this morning. His manna is here for me to gather today. He will be faithful to carry me today and every morning I wake up to another day in this life. Christ Jesus said Yes to the Father and He laid down His life, and it was through this very act that He overcame the power of sin and death. He found His life because He laid it down before the Father. So as this day dawns I know death will not have the last word. My sin will not have the last word. All these sorrows will be redeemed. Life will rise up and all our tears will be wiped away.

“Do you not know that all of us who have been baptized into Christ Jesus were baptized into his death? Therefore we have been buried with him by baptism into death, so that, just as Christ was raised from the dead by the glory of the Father, so we too might walk in newness of life. For if we have been united with him in a death like his, we will certainly be united with him in a resurrection like his. We know that our old self was crucified with him so that the body of sin might be destroyed, and we might no longer be enslaved to sin. For whoever has died is freed from sin. But if we have died with Christ, we believe that we will also live with him. We know that Christ, being raised from the dead, will never die again; death no longer has dominion over him. The death he died, he died to sin, once for all; but the life he lives, he lives to God. So you also must consider yourselves dead to sin and alive to God in Christ Jesus.” Romans 6:3-11

I grew up in a land of unfoldings. A land where one must bend low, look now, another unfurling. A land of delicate magic, intricate. Stepping over branches slick, footsteps quiet on the soft underfloor of forest. Ferns unwinding, their beings all folded up tight in complex arrangement, arching their backs, rising toward the light filtering down to them from high in the silhouettes of tree tops. Little ferns with leaves paper-thin, bright green in direct light, countless shapes repeating. Fuzzy juicy stalks and delicate sleek black ones. Mosses creeping, covering like downy shawl a glorious, vigorous green. Everywhere lush. I recall making a fern fort once. Ripping up scores of Lady Ferns, weaving them into walls and overhanging. I lay down upon the mossy floor and looked up through that scattered light, the greens bright like stained glass. Ferns and moss, resplendent greens of life unrelenting, delicate yet most resilient. Two gifts of this earth instantly inciting glee in my heart. Like Thoreau, I repeat, “I think my own soul must be a bright invisible green.”

And birds. Oh the birds. Fat breasted robins calling in the early morning when light has only begun to seep. Chatterings, bushes alive with tiny throbbing birds. Evening calls as day calms toward night. The days are lengthening. Crocuses and daffodils thrust up from the dirt. Cherry blossoms pink, forsythia and azalea. Tiny white clusters like thick stars on the limbs of apple trees. This is something Washington has that our home in Montana never will. Spring. Winter turns almost suddenly to summer in Montana and doesn’t come until June. But here, in this land, the drear of February, a time when the weariness of winter starts to become intolerable, it catches you off guard…there, did you see it? Stirrings. Hints that winter will not forever stake its claim. In the cold of ground and the rigidness of trees and branches, life still courses. Somehow what looked vacant, dead, unmovable, is everything to the contrary. Nay, there is an overcoming, some inner working unseen to my eyes, yet with such vigor as to burst through rock and soil and press out of wood and limb. A draw from distant lands, a call for the birds to return.

Spring is as sure as anything in this life. We know it deep in our flesh, our own veins course with anticipation. An inclining. An unconscious arching toward light, a yearning to feel warmth of light and freshness of breeze. Some mineral tang on the tongue that declares life never ceases, though all appears to disagree. That’s what we’re banking on, that is what moves us through our days. A hope. Hope. Such an overused word. But no, no. It is not merely some ancient knowledge that the earth will continue spinning on its axis, marking countless days and nights and a relentless orbit that will always swing back toward sun. No. Hope is unique to our humanity. Hope looks about and not only says, but proclaims, what I see now is not all that there is, there may indeed be more and different. Hope looks forward. Hope is the very essence of endurance.

There are stirrings in the woods, stirrings of song and light and delicate unfurlings that press against the dark and the cold. It makes me giddy. Giddy that death will never ultimately overcome. Giddy that the world is arcing in its orbit toward the sun. Giddy that one day the land will be bursting with life and the sun will rule the day and their will be an unstoppable flourishing. Abundance will mark life. No longer scarcity. No longer mere grasps at survival. No longer decay and death. The greens are unfurling. The birds have begun to call out to the morning. Spring is that tangible bright expression of the hope that courses through me.

And I have much to be giddy about. Hope abounds.

The land is wakening and it lightens the step and everywhere there is more to smile about. And Allistaire is doing just so surprisingly well. Dr. Sohel Meshinchi, our current BMT (Bone Marrow Transplant) clinic attending doctor, has ended our last several clinic visits with the statement, “I have no concerns.” This is like balm to the feverish forehead of a cancer parent. Her labs continue to look great and even improve. Her red blood and platelets are recovering, with platelet transfusions being spread out to one or two a week, whereas they had been every day to every-other day. Robin, our clinic nurse the other day said with glee, “Look Jai, look here at her ANC (Absolute Neutrophil Count), it’s normal.” She looked at me with shining eyes. Normal. 2,612 What an amazing number. What a wonder?! Normal. Imagine that!!!! Her liver function numbers have improved substantially and are only slightly high, her kidneys continue to do well and her BNP (measure of heart distress) was down to 119 the other day, a gorgeously low lab value. She continues to be CMV negative (Cytomegalovirus which can reactivate). Her weight is good as her appetite improves and taste buds return to normal. She has begun to eat salad, and even declares its tasty with the exception of the one half of one grape tomato I force upon her which causes her to dramatically grimace and gag every single time. She skips and paints and rides her bike and sings really loud with her headphones on.

Today marks Day+43 post transplant. We are still very early in this very long process. My brother asked me a while back, when we would know if the transplant was successful. Success is multi-pronged in this situation. The first mark of success is that she has survived the actual transplant process itself. Her body and specifically, her heart was not overwhelmed by the cytokine storm of the infusion of the donor cells, nor the hyper-hydration necessary with the chemo. The cyclophosphamide did not cause the slim but terrifyingly possible acute heart damage. Her lungs did not bleed nor did she have the brain damage possible with MMF. Her liver remained healthy despite the increased risk of VOD brought on by several rounds of Mylotarg. Her graft did not fail, rather Sten’s cells have latched on forcefully resulting in 100% chimerisms. Her marrow is clear of detectable cancer both by Flow Cytometry and cytogenetics. Thus far, her transplant has been a success. It is a beautiful surprise. Allistaire’s golden birthday is coming up soon and honestly, as I look back, this is the fifth birthday that I never knew would come and had much reason to think it never would. It is the fifth time we have had cause to celebrate life that might not have been, life that has been relentlessly hounded by cancer. But hope has continued to mark our days, and now years.

This next phase of transplant continues to be about making sure the cancer is kept away and about being on guard for GVHD (Graft Versus Host Disease). Every two weeks she gets a LP (Lumbar Puncture) in which Intrathecal Chemo is given and a sample is withdrawn to check for disease. This means chemo is placed directly into her spinal fluid as it can be a “sanctuary for leukemia,” given the blood/brain barrier that does not otherwise allow chemotherapy to pass through. While CNS (Central Nervous System) relapse is less common in AML (Acute Myeloid Leukemia) than in ALL (Acute Lymphoblastic Leukemia), the more common form of childhood leukemia, it is still a danger. She will get 5 LPs in all post-transplant. So far, her LPs have not detected any cancer in the spinal fluid. She will also be getting a BMA (Bone Marrow Aspirate), and PET/CT on March 15th. Typically BMAs are done post transplant only on Day+28 and Day+80. But for high risk patients they include another intermediate BMA. March 15th will be her first PET/CT since November and before her last round of chemo pre-transplant. At that time, her body was clear of chloromas with the exception of those in her sinuses, which had reduced in bulk from the previous round of chemo but were still present along with one new small chloroma. While her sinuses received 5 fractions of focal radiation and her body was barraged with TBI (Total Body Irradiation) and systemic chemo (fludarabine and cyclophosphamide), I am still nervous about this upcoming scan. Her cancer has defied countless assaults, its tenacity awe-inspiring and terror invoking.

At this point, there is no evidence of her disease. I rejoice at this and simultaneously remain on high alert, knowing “no evidence of disease,” in no way means we can confidently say there is no disease. The other significant issue the doctors and I are ever watchful of is GVHD (Graft Versus Host Disease). GVHD is when the donor cells attack the host (Allistaire), most commonly in the skin, gut and liver. GVHD is always a concern in bone marrow transplants but especially so in Allistaire’s case because of the much greater mismatch to Sten. Common symptoms of GVHD include skin rashes, tummy pain which can cause the patient to stop eating, diarrhea, and elevated LFTs (Liver Function Tests). There is a strange love-hate dance with GVHD. GVHD can severely impact quality of life and even cause death. What starts out small can suddenly turn into “rip-roaring GVHD,” so caution and response is necessary. But the treatment for GVHD has its own consequences. Immune suppressants such as prednisone and cyclosporine are given to tamp down the aggravated response of the T-cells. However, not only can these drugs have devastating effects on bones and joints (it’s not uncommon for teenagers to get hip and knee replacements), but the rest of the patient’s immune system is suppressed along with the T-cells causing the GVHD. This means the body’s ability to fight infection is radically diminished, again sometimes resulting in death from infection. In addition to the complications to be avoided from responding with medication to GVHD, the doctors actually want some GVHD. The thing is, when the donor cells are ramped up and attacking the host/patient, there is also the potential for the GVL effect (Graft Versus Leukemia) or GVT (Graft Versus Tumor in non-leukemic transplant patients). This is the secret weapon of stem cell transplants, an army roving the body to wipe out anything foreign which includes any lingering cancer cells. The hope of a transplant as a cure for cancer does not rely solely on the intensity of the conditioning, but rather, the more sophisticated element of the transplant is its micro soldiers that infiltrate the whole body and have the lasting ability to eradicate cancer. This is the “immunotherapy” element of a transplant. This is where I swoon. Don’t you just love it? And it has taken decades of research to begin to tap these mysteries.

A virus has taken up residence in Allistaire. Interestingly, it is a virus which even the most sensitive viral tests at SCCA cannot identify, never the less, she has had copious amounts of snot and some coughing. It is her first cold in over a year at least. With this virus we have seen what may be a small flare of GVHD, evidenced by a red spotted rash on her cheeks, spreading out from near her nose. Additionally, there seems to be a bit of a bumpy, slightly patchy pink rash on parts of her arms, back and chest. I was instructed to watch carefully for its advance both in terms of spread and speed. When Allistaire received the infusion of Sten’s stem cells (say that 5 times fast), she was given some mature blood cells from his peripheral blood but primarily his stem cells. Because the mature blood cells she received from her have mostly died out at this point, the immune fighting cells in Allistaire’s body are immature and have never been exposed to pathogens and are presently “uncoordinated” in their assault on this viral invader. Hence, both the virus and places like her skin are under attack. Apparently this pairing of having a virus and a flare of GVHD is very common. In fact, when there is evidence of GVHD, the doctors then go looking for an infection.

The other possible cause of this potential GVHD flare is the removal of one of her immunsuppressants and the tapering of the other. According to the protocol for her transplant, her MMF was to be stopped at Day+35. Typically at SCCA they would rather taper the MMF rather than stop it abruptly. However, Allistaire has clearly and repeatedly demonstrated that she has very aggressive disease putting her at extremely high risk for relapse even now. Removing the immune suppressants releases the hold on the T-cells which we hope will identify and wipe out any remaining cancer cells. For this reason, the doctors are very motivated to remove all immune suppression as rapidly as is safe to do so. So about a week ago her MMF was stopped all together. Then this Monday, 2/22, we began to taper her tacrolimus on Day+41, whereas the protocol calls for the taper to begin on Day+180. During this tapering process, she will be “watched like a hawk,” as the BMT staff seems to like to say, looking for any signs of GVHD and potentially backing off or slowing down on her taper if necessary. I am told that in these Haplo transplants, it is more common to see GVHD later than in unrelated-matched donor transplants (probably because of the post-transplant cyclophosphamide). More typically, acute GVHD is seen around Day+60 and later.

There is in the transplant world a magic number. One-hundred. One-hundred days is a song, like some mantra, some enchantment, a mystical goal out there in the fog. The standard is that, baring any serious complications, a patient’s Hickman line is pulled on Day+100 and is allowed at long last, to return home. I haven’t calculated the date exactly, but I know in Allistaire’s case, Day+100 is somewhere around mid-April. It’s out there. The date I avoid, I skirt around. I only allow it to linger in my periphery. I will not look it straight on. I am too well acquainted with disappointment. I keep my head down and we trudge on, willing ourselves not to be tired, not to be discouraged.

In August 2013, I was told in the most direct way, that Allistaire’s only chance for survival was a second bone marrow transplant. At that time, she was only Day+50 post her first transplant. You must wait an absolute minimum of six months between transplants to even have a chance of survival. For us that meant December. December was impossibly far off and the idea of going through it all over again was the most overwhelming moment of my life. People say the day of diagnosis is the worst. I most heartily disagree. When you are diagnosed, most of the time you have a plan, a means of response, hope that you can make it through. But what about when you’ve done the thing you came to do? You tried the big gun. And it just didn’t work. It wasn’t enough. And now your foe is even stronger than when you first began because it has mutated and become resistant at the very same moment that you are at your weakest, your most worn-down. But then Allistaire went back into remission with one round of chemo and there continued to be no more evidence of her disease as she completed a total of seven rounds of chemo post transplant. So when the day came for her one-year post-transplant follow-up and all looked well, I kept quiet. I was so very tired you see. I never asked about that second transplant. I just smiled and let myself finally feel a bit at ease.

Looking back, I understand the depth of that woman’s fatigue, but part of me screams, “You fool!” What if we had done that second transplant then? Her body was in great shape. No heart failure. No evidence of disease. A perfect time really for a second transplant. But I didn’t ask. I was tired. I just wanted to run as fast as could out of that cancer world and have a shot at normal life. Well, really I can’t remember if I asked or not. But even if I did, I must have accepted that answer. I’m not going to let that happen this time, no matter how weary I may be. I keep pressing the question. What are we doing to help prevent relapse? Okay, okay, we’ll do that, but what else can we do? What about this? What about that? As with so much in the world of cancer treatment, we are dealing in the world of utter unknowns. Dr. Meshinchi told me today that Allistaire’s specific MLL (Multi-Lineage Leukemia) translocation where chromosome 11 just broke off and attached to another chromosome, is unique among the 3,000 pediatric AML samples he has in his database. There is no data to say what someone is Allistaire’s very unique situation most benefits from. And every form of treatment has the potential for side-effects and the question is always, are those potential risks worth the unknown, untried benefit?

For now the plan is this: we will rapidly taper off all immune suppressants as fast as possible while trying to avoid GVHD in any severity. The hope is to allow the T-cells to have the brakes taken off of them and allow them free reign to roam wide and vigorously to eliminate any remaining cancer cells. Ironically, if there is no evidence of GVHD, we are planning on a bold move, rarely attempted, to elicit a GVHD response. The goal is to be off of all immune suppressants by Day+100 and if at that time there has been no evidence of GVHD, Allistaire will be given DLI (Donor Lymphocyte Infusion). DLI is an infusion of just lymphocytes from Sten. There are probably enough stored cells from his stem cell donation to get the necessary number of lymphocytes. If not, he can do a simple blood donation which would not require GCSF shots because it would not include stem cells. These donor lymphocytes would be infused into Allistaire in hopes that the white-blood cell hunters will recognize Allistaire as foreign and go on the war-path. Soheil does not recall them ever trying this “prophylactic” DLI approach. DLI has been given in the context of minimal residual disease in hopes to wipe out tiny bits of cancer, but never or very rarely when there is no actual evidence of disease. If she were to get DLI and it was well tolerated, she would be given a larger second dose about a month later. This also means that we have a good chance of having to be out in Seattle longer. It is all a matter of waiting and seeing.

A few weeks ago I found myself feeling extremely down, baffled and frustrated with my deep sense of sadness. We had just been discharged from the hospital and moved into our apartment at Ronald McDonald House. Allistaire was doing amazingly well, yet I could not shake saturating sadness. It was an act of will to hold back the tide of tears threatening to swamp my little boat. Perhaps like a runner in an ultra-marathon, having finally made it through transplant, I found all my reserves of energy come crashing down. I felt tired to my very core. When I tried to force myself to look up, all I could see were the sad, tired faces of my friends who have lost their children. I kept thinking of Stevie and Lilly reduced to ashes. How many? Sara, Ruby, Mario, Benton, Jaxon, Tristin, Christian, Pantpreet, Nolan, Jordan, Marleigh, Howie, Cyrus, Zach, Karlee, Bella, Lilly, Stevie. These are the children who have died in the time Allistaire has been in treatment – children and/or their parents that I have known – not even close to the total number that have died. These are the faces I have known. Though I have much to rejoice in with Allistaire’s progress, it has sometimes felt like her death is inevitable, just a matter of time. Sometimes my whole vision is consumed with the bright faces of children gone still. Home and a life freed from the grips of cancer sometimes seems like an impossible dream.

But there are stirrings see? Whisperings. Eyes a blaze with zeal. Minds whirling with ideas. Happenings. Little discoveries and victories that are starting to turn the tide. As the earth has reached the furthest reaches of its orbit, it has begun its journey back toward the sun, the earth warming and throbbing with life, unfurling. There are stirrings too in the world of cancer research. Great wonders have begun to be revealed. While it has literally taken decades and decades of research to get here, there is now starting to be a new world of promising cancer treatments which look in and down to the genetic level, down to the world of molecules. Immunotherapy, in which the intricacies of a patient’s own immune system is harnessed to track down and obliterate cancer while sparing healthy cells, is making incredible advances. Like a wild-fire that starts with a mere spark, so it seems is the world of immunotherapy. There is hope that the world of cancer treatment is on the verge of a tremendous revolution. There is hope that we are on the cusp of seeing a future for cancer patients that will look radically different from that dominated by the standard weaponry of chemotherapy and radiation.

Right at the center of this immunotherapy revolution in cancer treatment is our much beloved Fred Hutchinson Cancer Research Center. Check out this article from The Huffington Post that tells about the successes of Dr. Stanley Riddell of Fred Hutch which has yielded amazing results: putting cancer patients who have failed all other forms of treatment into remission at staggering rates using T-cells. Everywhere I turn at Fred Hutch there are new amazing trials and areas of research underway. Allistaire’s clinic attending, Dr. Soheil Meshinchi, and our dear Dr. Marie Bleakley are working on designing TCR T-cells that target highly specific proteins found only on leukemic cells. I sit and ask Soheil question after question and listen with mouth gaping, on the edge of my seat, eager to hear where the world is headed.

But there have also been moments as I’ve sat in wonder that I also find myself grieving. All of these advances are far too late for the eighteen children whose names I listed above. Much is even too late for Allistaire. Just four years have passed since she was first diagnosed and already the treatment of AML has changed. There are new tests done at the point of diagnosis to better determine what course of treatment works best with the individual’s unique disease. There are new treatment options that simply did not previously exist. It was only in April 2012 that the very first child was treated with genetically modified T-cells. I wonder what it would be like if Allistaire were diagnosed today, rather than four years ago. How much better would her chance of survival be? I also hear Soheil mention over and over again, “it’s a matter or resources…if we had the resources…” Resources!!!!! Sometimes I want to scream. So you mean, if you had the resources you could do this and this and this and give my child the treatment she so desperately needs? But you see, resources are scarce and government funding has been in short supply. These very brilliant, intelligent brains that should be devoting their time and energy to research, to what their good at, have been having to run around trying to scrape up money to keep their labs going, to find a way to pay to design that test, that piece of equipment, get the research from the lab to treatment in the clinic.

You know what I want to see? I want to see cancer research accelerated so that fewer kids and moms and brothers and friends have to have their lives cut short. I want to see treatments that actually cure! I want to see treatments that cure without poisoning hearts and kidneys and brains! I want to watch in wonder as scientists learn to use our very own beautiful, wild, amazing immune systems to obliterate cancer. And science is science – all these advances in understanding the genetic base for not only cancer, but for so many diseases, and how to make genetic modifications and therapies promises to benefit lives touching each one of us!

I’m going to get on my bike again this summer of 2016 and ride to accelerate research, to save lives faster, to obliterate cancer. I’m on Team Baldy Tops again this year in Obliteride and I’d love to have you join us! Come on out the weekend of August 13-14th and ride with us. There are routes for every skill level, from 10 miles to 150 miles. If you’re not up for riding, you can still join our team as a virtual rider and raise funds for cancer research. And easiest of all, you can donate! One-hundred percent of all funds raised in Obliteride go to cancer research at Fred Hutch!

Hope is being able to imagine a world that looks different than it does now. The cold and dark of winter is turning toward the bright zeal of spring. One day kids diagnosed with cancer won’t have to die, but can be cured and go on to flourish in this life. One day your mom, your wife, your sister, your daughter won’t have to fear breast and ovarian cancer and having to make the brutal choice of whether or not to cut out chunks of her womanhood. One day you won’t have to watch your dad whither away or lose your best friend. While my ultimate hope for life overcoming death rests in Jesus Christ and His promises of redemption, resurrection and a new heaven and a new earth, it is joy to see His grace in this lifetime as this vicious disease has begun to meet its match.

I will ride in Obliteride again this year because I will forever be indebted to Fred Hutchinson Cancer Research Center. Allistaire would not be alive today were it not for the research, the clinical trials and the treatment she has received through Fred Hutch. I ride in gratitude for my child’s life. I ride in sorrow for the children I’ve known who have died. I ride in hope for cures for cancer!

Turning this way and that, buffeted, battered. Every angle met with contradictory force. Joy, relief, yellow, bright splintered through with black, tears. Flashes of bodies warm gone cold. Flashes of giggles and bright eyes and stiff bodies born down hallways blocked from the eyes of the living. Friends gone. Gone. Turning east, car seats empty. We should NEVER go east without those faces in the rearview!

And I sit in sunny room, a palatial expanse, hum of the dryer and a sudden home, a grocery list and kitchen utensils and a recipe. Sixteen months and the first meal cooked. Not microwaved. Not to-go styrofoam from a restaurant. Ceramic plates. Glasses. Imagine: a refrigerator, a stove, a sink, a table, a child, all in the same room. No flights of stairs to run up and down to heat up yet another hotdog. For the first time in sixteen months, I sat in a cushy chair in the early morn, coffee and book in hand. Wonderment. Grandeur.

I walk out into that cool of night, crystalline stars blue and white, sparkling, not trite but truly, they sparkle. How long since I looked at stars? There, Orion’s belt. Stars countable in a city sky. I walk the 30 feet from the Ron Don Apartments solely for those patients discharged from bone marrow transplants, into Ron Don’s House A. A familiar face and a story. Kidney failure from a culprit whose name I know so well, drawing its milky substance into the syringe, three times every day, waking her every night at 2am. “Allistaire, Allistaire. Wake up sweets. It’s time to take your med.” Up she rises in the dark, half-asleep, trusting, mouth open. And little John, little John. “But I thought they went home?!” my voice a near quiet wail. He bled out. Just blood everywhere. But, but…his platelets? No, they were high enough. His clotting factors then? No. No. His cells just broke open. He bled out. Another family swept away east, empty-handed.

I stumble back through the night air, to my spacious abode, to my bald-headed girl. Bright. Cheery and spinning. And I draw up the meds, again and again and she opens her mouth. Trembling at the huge chunk of magnesium. Shaking at the sight of that fish oil capsule. But you must. You must! Press forward, rush at that pill before it gets the better of you. Defy it. Don’t look at it. Don’t think about it. Just do it. Put it on your tongue and swallow! Can you not hear the pounding of some monstrous hooves? The breath hot and rancid on your neck? The flying of rabid saliva. Run Allistaire! Run child, run! We must keep running, I silently wail. And the ashes of children, children whose voices I have known, ashes of eyes that once were bright, falling, falling all around us. Ashes on our cheeks, ashes in our hair.

And upon the wall I’ve hung the art, the endless rainbows of color. The cheery felt flags and the string of butterflies. I’ve purchased bins, bright taffy pink bins with lids, little woven bins of lemonade yellow. The lip glosses go here and the legos there. Spread out the new Ikea rug across the cold faux-wood linoleum. Set the picture frames upon the tables and cozy up to lamp light.

We escaped. Maybe. But who are we that we should be any different? Who am I that I should be allowed to keep my child? I watch the eyes of my friends. I reach out and know they are impossibly far away. They dwell on the other side of that gulf. People say, “So, one-hundred days huh? And then you get to go home, right?” You see, I never imagined we would even make it to this day, this twenty-eighth day post transplant. Allistaire’s done so well, she discharged from the hospital last Wednesday, February 3rd, in near record time. A mere twenty-two days post transplant and after a short 46-day inpatient stay, Allistaire walked out of that hospital into the light and air of the outside world. And I felt relief and awed shock. How? How did it go so well? How was it so incredibly easy?

The very next day our out-patient life began with a full day of clinic appointments at SCCA (Seattle Cancer Care Alliance). I hadn’t prepared my heart, just read the times dictated to me. Go here, go there, at this time she’ll get her blood drawn, meet with the nutritionist, the social worker, the pharmacist, the nurse, the attending physician. Yes sir, yes ma’am. We do as we’re told, we open our mouth and move our feet to their instruction. I’d forgotten the stares. The stares of adults with cancer taking in the image of a small girl, bald like themselves. A sort of horror and wonder in their eyes as they take in the smooth curve of her cranium, little blond hairs sporadic at her crown and nape, tubies peeking out from under her shirt. I’d forgotten the sight of great swelling cheeks, cheeks that no obesity could fashion, cheeks like grapefruits, the effect of steroids unmistakable; steroids the primary defense against GVHD. She seems to have made it out alive from transplant, but there it is, staring us in the face, the next beast threatening to devour and the perverse desire for it to come. Yes, GVHD (Graft Versus Host Disease), you are welcome here, we invite you, come, come devour, come eat alive the ever-present threat of those mutated cells. And I gag at the thought. GVHD can kill. Kill outright or kill by slowly stealing away quality of life. And yet, not even radiation on par with a nuclear blast, not round after round of ravaging chemo is enough to trust those bastards are gone.

Walking in the doors of that building, going to the 6th floor for the transplant clinic…it all comes sweeping back, a flood of memory, the terror that rose, water to the neck. Abrasive, the memories admonish, don’t let down your guard, don’t feel at rest, muscles stay tense, eyes alert, edgy. When is it coming for her? When will it strike again? Only 50 days after her first transplant in June 2013, her cancer showed itself again. Will we ever, ever be rid of it? Will this crazy life ever end? And you tell yourself to shut your mouth. Your friend, whose hand and the cold hand of her daughter you held, tells you she would given anything to be in the fight again, just to have her little girl with her. So don’t you dare weep for the ravages of your life, for she is with you! She is here! But will it ever end? Oh God, must it end that way to end? She had her Day +28 bone marrow test yesterday and her chimerism test to determine what percentage of her marrow is her own and what is donor. How long might we enjoy this reprieve?

Dr. Cooper saw her in the hallway yesterday, and said, “She just looks SO good!” Words echoed by many, many that have walked long on this journey with her. Yes. Her eyes sparkle with glee. You should have seen the enamored wonder in her eyes as she spun in her new room, her own room in our Ron Don apartment. “I was squealing getting into the car,” she tells me, “all my dreams are coming true!” she grins. I cried when I walked in the door of our apartment for the first time, less than an hour after hugging Stevie’s parents, Keshia and Michael, and grandmother, Linda, goodbye, knowing they had one last stop before traveling east on I-90. They were headed to pick up Stevie’s ashes. And I was headed into a new apartment and post-transplant life. Tears that they had a U-Haul trailer full of Stevie’s toys, toys to pack away in a storage unit, and I, toys to pull out of boxes to set up in anticipation of Allistaire’s joy. Tears that we have this gift we’ve done nothing to deserve. Tears that this present lull in no way guarantees we have escaped the same outcome. Tears for a home that is not home. So weak the prayers, “Oh God.”

Allistaire is doing wonderful so far. She has clinic days at SCCA each Monday and Thursday, with frequent lab draws in-between due to the ongoing need for transfusions, especially platelets which are the last to recover. She engrafted on Day +20 with an ANC of 2050. Her ANC has since dropped due to no longer getting the GCSF (Granulocyte Colony Stimulating Factor) infusions, but today was 630. Allistaire has not had an ANC that high for nearly a year and a half. Her medications continue to be adjusted as drug levels are taken and electrolytes change. She gets 35 doses of meds per day which include the immune suppressants tacrolimus, and mycophenolate mofetil (MMF), hydrocortisone to compensate for the insufficiency of her adrenal glands, acyclovir to protect against certain viruses, voriconazole to protect against fungus, dapsone to protect against pneuocystis, ursodial to protect her liver, fish-oil to reduce her high levels of triglycerides, vitamin D supplements and a multivitamin. For her heart she takes hydralazine, isosorbide dinitrate, carvedilol, lasix, spirinolactone, magnesium supplements and Entresto.

Her higher ANC betrays the true weakness of her immune system. Because her transplant wiped out her immune system, it also wiped out the immune effect of the vaccinations she has received, with the exception of chicken pox because that lives in the nerve cells. It will take an entire year for her immune system to fully reconstitute. Only then will she be able to get re-vaccinated, for the third time in her life. For this reason, for one year post transplant she is not allowed to attend school nor any event or go to any location with a high density of folks. We venture out with caution, at off times, mid-day, mid-week when we must go to the store. She cannot dig in the dirt, cannot frolic in the grass, must avoid house plants and all sources of fungus. Her food must be more carefully washed and cooked to avoid food born illnesses such as E. coli, Salmonella and Listeria.

We walk forward in hope, though it is not a bright and refreshing hope. It is the hope of the hunted. It is hope that there may still be a way through, though the dangers great. It is a hope permanently stained with images of those who have fallen, images of tear-stained faces of friends, bodies lining the road behind. It is a hope that feels a bit crazed and frantic, a panting from hard running. It is a hope that yearns for a day when this fleeing may cease and a weapon will have been crafted that can be thrust deep into the heart of that beast, killing it forever. For now, we strain forward, seeking to feel the warmth of sun on our faces, never taking one moment of life and bounty for granted. My prayers are short. “Thank you God.” Thank you for this ice amazingly ever available in this freezer. Thank you God that every time her platelets drop there are platelets ready to replace the empty space. Thank you God for an oven to bake cookies in. Thank you Father for that giddy joy she has as she places the chocolate chips in the pancakes. Thank you God for the hope that we will see Solveig soon. Thank you God that Allistaire is almost 6 years old. Thank you that though we have been chased relentlessly for four years, her life has tripled from what it might have been. Thank you God for every time I get to hear, “I love you Mommy.”

And I cry out to the Lord on behalf of those who have lost their little beloveds. Oh, Lord. Oh Lord. Have compassion. May your Spirit go out from you and dwell within those broken, bleeding hearts. Comfort with the comfort that only You can yield. And do not turn away from this ravaging, God! Come quickly! Bring an end to this brokenness. Redeem the loss. Raise the dead. Bind up the wounds. Put an end to the curse and bless. Wipe away the tears. We are expectant for You!

And Father, though we run as those chased, let us simultaneously find our rest in You, our only home, our very life. May times of refreshing come to my heart, dependent on You, not on changed circumstances.

My friend lost her baby girl the day before she was to be induced. She had to push out a child not breathing. Only months later she learned she had cancer, at just about the same time she found out another child was on her way. Now there is a bright, smiling baby girl in her life and tomorrow she finds out if her cancer has stayed at bay. Her longing is that she might be singing when the evening comes, no matter the results.

Yes Lord. May we sing out, even as tears stream down, let us bow low and worship and fix our eyes on You.

(Got a call yesterday evening with Allistaire’s bone marrow biopsy results…0% detectable leukemia by Flow Cytometry and 100% Donor Chimerisms in both the peripheral blood and marrow – this means only Sten’s/Donor’s cells are detectable and nothing of Allistaire’s old immune system, including her cancer, is detectable at this point. What an incredible grace of God. Thank you. Thank You Lord!)

Were it not for the last 24 hours I would have chosen a different title for this blog post, but the past day has been such an odd contrast to the preceding seven days that I can state only that we are eight days into this thing.

The first seven days of this transplant have been marked with Dr. Bleakley being remarkably smiley and saying on several occasions that Allistaire is doing better than she thought she would. This in turn has made me smile a lot as well! When Dr. Cooper stopped by briefly yesterday to check in on us, he was taken aback that when asked how I was doing, I responded, “Ecstatic.” Because, really, really, it is simply still a startling wonder that transplant has happened. What happens going forward is simply a matter of having to accept and respond to. No longer is there the great weight of, “will we make it to transplant, will this stop us?” Even her heart, though of course we want to continue to vigilantly care for it, no longer is a barrier to moving forward with this radical intervention of therapy. And as I said, the week has gone amazingly well.

Allistaire’s fever on the evening of her transplant was the first of about six. Blood cultures are drawn every 24 hours within which there is a fever and all continued to be negative for any evidence of infection. In addition, despite wrapping up her Flagyl therapy for C-Diff, she actually had increased diarrhea. The fevers and diarrhea, Dr. Bleakley told me, is evidence of the cytokine response happening within as Sten’s cells entered a foreign environment. Dr. Bleakley was quite pleased with this degree of cytokine storm as it was evidence of an immune effect happening but not one that raged out of control and seemed to impact her heart. Though all of this did make for some rough nights for both Sten and Allistaire as there were countless poopy diapers to change.

On Friday morning, January 15th, Allistaire had an echocardiogram and EKG to serve as a baseline going into getting Cyclophosphamide/Cytoxan and the associated hydration used to counteract the common side effect of bladder bleeding. Her function remained consistent with the previous echo done in mid-December, though her heart was very slightly dilated (2mm). Dr. Law was pleased with how she had weathered the first storm of this transplant. Her heart rate had also been quite elevated (150-160s) for several days which could not be accounted for by any measure of her heart function. He assumed it was related to the oncological realities happening with the fevers and cytokine effect. Indeed, once the cyclophosphamide wrapped up two days later and the fevers subsided, her heart rate down-trended nicely to 100-120.

Friday and Saturday she received one dose of cyclophosphamide each day in addition to hydration at 1.25 times her maintenance rate. Additionally, she was required to urinate every two hours with the urine being tested for blood. Thankfully, other than once when her platelets were very low, she either showed absolutely no blood or only the most trivial amount. The possibility for an acute cardiac hit was also monitored by tracking her BNP (Brain Natriuretic Peptide), a measure of heart distress, and troponin levels, which are evidence of heart muscle cell death. Thankfully, so far her troponin level has remained essentially undetectable which means there is no evidence of heart muscle cell death and her BNP has been low. A repeat echo was conducted on Monday and showed a slight decrease in heart function with an ejection fraction down from 42 to 37 and a slight additional increase in dilation. However, the cardiologist remained please with how well she had tolerated all of the hydration. Allistaire showed absolutely no signs of burden from what she went through. Her lungs have been clear and all clinical assessments have continued to be excellent.

The plan was to move Allistaire upstairs to the cancer unit after one final day in the ICU after the end of hydration. So yesterday afternoon we moved back up to the cancer unit into the very room we left a week prior; a room with a great view, Forest 7 room 219. Tuesday had been a day mostly spent waiting to move upstairs and by 4pm she was finally settled in for a nap in her old room. I headed out of the hospital for a few errands and just before 6pm got a call from the nurse that Allistaire had a raging nose bleed. I could hear Allistaire hysterical in the background. She had a horrific nose bleed back in November which was increasing her terror with what she now faced.

While I was on the phone, driving back to the hospital as fast as rainy congested streets allowed, I made sure to ask that platelets had been ordered STAT! Yes, yes the word came. When I walked into the room there were countless bloody tissues and the sweet BMT PA, Agne, attempting to help Allistaire with holding her nose. I took over nose clamping duties while we waited desperately for platelets to come. An hour passed and I kept being told the platelets were on their way, almost here. Allistaire was settled for a while with me clamping her nose with shocking grip. I was actually in awe that my hand muscles could keep up with the demand on them. For a while Allistaire had calmed and quieted but then with absolute terror in her eyes she shot up and screamed that she needed to throw up. What came out can only be described as what it might look like to hurl out of your mouth a gutted-animal, so thick and plentiful was the curdled and clotted blood (see very last picture at end of post). It was horrifying to watch that projecting out of her mouth. She cried and screamed and I’m sure must have felt like she couldn’t breath with her nose clamped and huge wads of blood filling her throat.

The platelets were still supposedly coming but were never arriving. I found myself getting madder and madder, sadder and sadder. To quote the movie, “Home,” I was “sad-mad.” I hated that my little girl had to endure such horrors; not just the repulsiveness and scariness of this, but the reality that her own body is under constant attack from a disease that destroys the part of her that is supposed to protect and sustain life. Yet, I was so very thankful that help was on its way despite taking a ridiculously long time. As I sat there clamping Allistaire’s nose, trying to calm her, trying to press down my own angst, I harkened back to reading about the realities of leukemia prior to the 1950’s, in a time before platelet transfusions. This is well described by Dr. Emil J. Freireich, who “still can’t forget his first exposure to childhood leukemia, the heart-rending and terrifying fatal cancer his boss instructed him to cure. Freireich, then a hotshot young researcher whose only knowledge of pediatrics came from medical school, took over the care of kids with the disease, kids with all manner of lumps, bruises, headaches, infections, fevers and, most of all, bleeding that Freireich says made the hospital unit ‘look like a butcher shop.’ Ninety percent of them were dead in a week. ‘You cannot imagine how horrible it was,’ says Freireich, 88, nearing his 50th anniversary at M.D. Anderson Cancer Center. ‘These were 3-, 4-, 5-year-old kids bleeding to death, bleeding out of their ears, eyes, nose, skin and bowels, bleeding internally, vomiting blood. It was a parent’s greatest horror.” (Legendary Oncologist Returns to The Limelight)

Finally, two hours later the platelets came; a simple little bag containing a minimum of 150,000,000,000 platelets. Sometime ago I learned that platelets are not actually true cells but are produced within a large cell called a Megakaryocyte, each of which can produce two to five thousand platelets. And until Dr. Freireich discovered that lack of platelets were what caused the horrific hemorrhaging and then developed a method to transfuse platelets, children with leukemia never even had a chance to really have their cancer treated, they just bled out and died rapidly. In reading up more on Freireich, I learned that he was also the first to have the idea to transfuse granulocytes and to develop a means for accomplishing this. He co-invented the continuous-flow blood-cell separator, was part of the research group that first began to use antibiotics empirically to control infection and determined that you start to bleed when your platelets reach 10,000 – this is the same threshold used today over fifty years later. Perhaps most significantly, Dr. Freireich and his closest collaborator, Dr. Frei (both had the first name Emil if you can imagine that?!), were the first to use aggressive doses and combination doses of chemotherapy to attempt to cure Acute Lymphoblastic Leukemia. They were met with extreme opposition but persevered and succeeded!

If I had my dream come true, I would sit down before Dr. Emil J. Freireich and attempt with all my heart to say thank you. Over and over my child’s life has been sustained because of his direct efforts and accomplishments! Thank you Dr. Freireich, before Allistaire was born, even before I was born, you labored endlessly in the face of incredibly opposition, belittling, and in terrible conditions because you were determined to find a way through for these kids. You don’t know her, but my little girl, Allistaire Kieron Anderson is alive today because of you! You! Her life is part of the fruit of your labor and once again I find myself deeply and joyfully indebted to total strangers. There is a yearning in me to thank this man, to look into his eyes, or perhaps to even attempt a great hug to say thank you a hundred-million times over. Allistaire might as well have been pulled from a burning house by a stranger, but not just once, over and over and over. I often find myself dumbfounded, gaping in the mouth of all we have to be thankful for, the magnitude of our abundance staggers!

And it continues! We had a few bumpy days but made it through. After the raging bloody nose on Tuesday night, Allistaire finally got all settled in bed for the night. I stood at the foot of the bed while the nurse drew some labs and I happened to have the monitor in sight when all of a sudden, Allistaire’s heart rate jumped from about 100-110 to 208 with a ragged tight swath of crazed up and down peaks of her heart rate. In a second it was over and I asked out loud, “what was that? I have never seen that!” I asked that Allistaire’s electrolytes be checked, thinking that with all that blood loss, they might be wacky and this can throw off the rhythm of your heart. The hospitalist ordered a STAT EKG and electrolytes were checked. Everything seemed normal with the exception of a lower potassium, but nothing crazy. So we went to bed finally around midnight. After waking repeatedly every hour for diapers and the nurse coming in, the doctor woke me about 4:45am to say there were going to call a RRT (Rapid Response Team). This is where a risk nurse comes and evaluates your child and determines whether or not more intense intervention is necessary and the child is often transferred to the ICU. What prompted this was another episode of what the monitor called, “VTac,” which refers to Ventricular Tachycardia. Because VTac can be very dangerous, Allistaire was transferred to the ICU where they could better monitor, and actually record for later review, her heart rhythm. So only about twelve hours after moving to the cancer unit, down to the ICU she went, into the same exact room, Forest 6 room 321. Good grief.

The next morning she had an echocardiogram to determine if there was any decrease in her heart function. A more dilated heart is more likely to have arrhythmias. Because she had thrown up a total of 450 ml of blood and the cardiologists want to keep her hematocrit above 27, red blood was ordered and got underway. And despite getting a transfusion of platelets the night before, because it was decided to raise her transfusion threshold from 10 to 50 to really stop the bleeding that might not only be in her nose, platelets were also ordered. So the red blood was paused while the platelets went in but the red blood expired (it only last 4 hours once the bag is spiked) before there was a chance to get in anymore than 60ml. Her hematocrit was checked again and it was down to 19 (standard transfusion threshold is 20 so this was exceptionally low for her). Blood was ordered once again. Throughout the day Allistaire was extremely tired and not at all interactive. She was incredibly worn out from the nose bleed trauma, a hectic night with countless interruptions, and a very low hematocrit. Our nurse had expressed several times how she just didn’t seem like her normal self.

We were hoping to get her blood started and down for a nap when the nurse discovered a tiny pin-prick of a hole in her red lumen. IV team was immediately called to repair the line and to also place an IV so she could get blood and meds that obviously couldn’t wait the 24 hours the line is out of commission while the glue in the repair sets up. Despite much screaming on Allistaire’s part, another nurse was able to place an IV in her hand and off she went to sleep, the blood flowing in. About two hours later, our nurse called me to tell me, “your girl is back and wants to talk to you.” Allistaire jumped on the phone and immediately you could hear the difference. Blood. Blood! She was alive! The little worn out girl who’d lost her spunk needed blood! Hey, have you donated blood recently? Ever? Perhaps this will sound pushy and rude, but really, if you say you love Allistaire, if you say you want to know what you can do to help, anything, well then, give blood! Allistaire would never, ever have a bit of chance to fight this cancer if it were not for the countless blood transfusions she’s received because real people were willing go give of their time and endure a wee bit of discomfort to give something from within themselves that can literally save people’s lives. Isn’t that wild? Can you cure cancer? Can I? Probably not, but she has no chance to try to see if this treatment works if she doesn’t have blood! Enough already? Maybe. And please, those of you that honestly can’t give blood…you lived in the U.K. for some period of time or were in a malaria laden country or whatever disqualifies you from giving, fine. No worries. I’m talking to all of you out there who can give blood and either are afraid or haven’t managed to find the time. Please. Please, for Allistaire, for so many whose lives could not be sustained otherwise, make a point to do it now!

Late in the afternoon the cardiologist finally came by to report that Allistaire’s heart function was totally stable, identical to the last echo. He talked with me at length about why he believed that Allistaire was probably just fine and suspected that what had actually occurred could have been SVTac, or Supraventricular Tachycardia, which is also an irregular heart rhythm that begins much higher up in the heart and is far more benign than VTac. She had no more episodes of irregular heart rhythms and he felt that by the next morning she should be able to safely go back to the Cancer Unit. I was so incredibly relieved. Just to ensure one more measure of caution, it was decided Allistaire would wear a Holter Monitor for 48 hours that can, in a much more detailed way, record her heart rhythm.

Once again we made the transition from the ICU to the Cancer Unit, back into our fabulous room 219 which they had held for us. With the concern for Allistaire’s heart fading a bit, the issue of her line came to the forefront. Allistaire was complaining a lot about her hand hurting where her IV was placed and when she kept screaming when the nurse tried to flush the line, it was determined that it had to be removed and another placed. In the mean time, the nurse attempted to flush the newly repaired red lumen on her Hickman Catheter, but to no avail. She could hardly get anything to flush through and she certainly could not get blood to draw back. So she put a dose of tPA (Tissue Plasminogen Activator) in the line and planned to wait an hour before trying again. The IV team came and after two failed attempts to get in an IV, they left for a while. The nurse then tried to flush and draw back blood again from the line but it still wasn’t working. At this point Allistaire is really worked up because she knows that if her line doesn’t work then she’ll have to get more IVs. And indeed, IV team came back, this time successfully placing an IV in the hand which is the same hand she sucks her thumb. She was horribly sad.

Then out of the blue I am told the ultrasound tech is coming to look at her line. At this point I’m totally confused because just the day before they did an X-ray to look at the positioning of her line with the concern that if the tip of the Hickman catheter is too far down into the ventricle of the heart, it can cause agitation and in turn stimulate an arrhythmia. Turns out the purpose of the ultrasound was to look at her vasculature in her neck and chest to determine where a new line could be placed. Before I knew it I was talking to the surgeons, signing consent and talking with the anesthesiologist about surgery for a new line to be placed the next day on Friday. All the while I was thinking, “HOLD UP!! Let’s just slow this thing down a bit and see if we can’t get this line working.” The BMT PA was concerned that because the line was so old, that the repair wouldn’t work and we needed to get moving on planning for a new line placement. Understanding her point but being none too pleased about the idea of Allistaire having surgery with no white blood cells to fight infection or about more cuts into her already scarred up body, I asked that we please try more tPA. This time it was left for two hours and it worked beautifully! Allistaire was beside herself with excitement that the IV was coming out. And her line has continued to work great and surgery was scratched off the week’s T0-Do’s.

Despite some rocky, odd days, Allistaire is doing phenomenally well! She is closer and closer to a true baldy top as most of her hair has fallen away, leaving only her signature blonde fringe at the hairline around her face and a scattering of hairs on the rest of her head that sort of makes her have a bit of a glow. She’s happy and hilarious. Her mouth sores have mostly healed and she’s able to take all of her meds by mouth with the exception of those that can only be given IV. She’s drinking her required fluids each day and eating enough calories to not need TPN (IV nutrition). Her labs and vitals have been great, lungs are clear and her heart seems to be doing well. Her really only struggles are keeping her platelets high enough to avoid nose bleeds and the mucositis in her bottom. Because radiation and chemotherapy are most effective at killing rapidly dividing cells, you lose your hair and the cells that line your digestive tract all the way from your mouth and out the other end, are damaged and die. So for Allistaire, it hurts really bad to urinate and poop. A urine sample tested negative for a UTI and for BK virus (Bladder Kidney Virus) which is what leads the doctors to believe this is just mucositis that will take time to improve. All in all she is just doing amazing! She tested negative for C-Diff today which means she is now only in Contact Isolation, not Contact-Enteric Isolation, which allows her at long last to leave her room and go for a walk around the Unit. So for the first time in three weeks, Allistaire had the freedom to walk the halls of the Unit. When the front desk Unit Coordinator greeted her by name, Allistaire raised her hand in questioning and said, “How did I get to be so famous?” Oh my.

We have twelve days of transplant behind us. Dr. Bleakley estimated that Allistaire would “engraft,” around Day+21. Engraftment is when the stem cells, infused into the peripheral blood, have migrated to the bone marrow and begun to reproduce. An ANC (Absolute Neutrophil Count) of 500 two days in a row is considered official engraftment. This is a bit longer of a time frame than you would typically expect in a Peripheral Stem Cell Transplant, but because she received Cyclophosphamide on Days+3 & 4, the timing gets elongated. But once her cells start to come in, she will finally have white blood cells that begin to repair the damage done by the chemo and radiation. Of course this is also when you can begin to see signs of GVHD (Graft Versus Host Disease). Her first bone marrow test will be on Day+28.

I am pretty much in awe of how things have gone thus far. I am so very thankful for each day we are able to walk forward. But my heart remains heavy, not just for Allistaire, but for other moms dear to me. At this time I think of my friend Julie Guillot, whose son Zach, was undergoing his third transplant for AML at this time of the year two years ago. His liver ended up suffering from VOD/SOS and he died in the ICU of internal bleeding on February 7, 2014. She and Zach walk these halls in my heart with me. I think of sweet Stevie up in a darkened room on the 8th floor. Fighting a raging bacterial infection and her marrow and blood full of leukemia with her newborn baby sister in the bassinet next to her, while her mom Keisha attends to her every need and her dad is back in Montana working to provide for his family. Keisha and Stevie might as well be Allistaire and I. What happens for them feels deeply personal to us. We hold them tight. I think of bright Ava who lives in Chicago, and who like Lilly did, fights bi-phenotypic leukemia which means her leukemia has characteristics of both ALL and AML. A year after her transplant, trace amounts of her disease has returned in her skin and marrow. Her parents strive to know what the Lord would have them do walking forward. I think of dear Heather, who everyday must live without hearing Lilly’s voice.

Yes, Dr. Emil J. Freireich contributed enormously to the fight against leukemia and is credited with a lot of why you’ll hear leukemia has a 90% cure rate. But not all leukemias are the same, and AML is a beast far, far different than ALL. Around half of children with AML will die. There is still a long, long way to go to get to such an amazing prognosis for children with AML. Won’t it be amazing one day when we reflect on these early years of the 21st century and talk about how it all changed, a world where most kids with AML died and then tenacious cancer researchers refused to give up, they pressed on despite all the obstacles. Won’t it be absolutely beautiful when treatment for AML doesn’t break hearts, literal and figurative?!

“For their parents, it was agony. In order to have a chance at life – they were told – their child had to be brought savagely and repeatedly to the brink of death.” Malcolm Gladwell, “David & Goliath”

So true. We walk forward into dark terrors because we have no choice, no alternative. I hope desperately that in the next fifty years, cancer treatment will look nothing like it does today and it won’t have such holistic ravaging effects. Lord hear our prayer!

You look out upon a field studded with rocks, rocks small that huddle together in the hand like eggs in a nest, fist-sized rocks, rocks you think if you gave them all your strength you could heave up out of that earth, hold to your chest, hugging them round with your arms. And here and there, a few scattered boulders. Boulders, monoliths, enormities that stand silhouetted against the sky.

How can I ever gather them all? The task overwhelms. Scattered all about they don’t look like much. Yet to convey the enormity of the day, one massive boulder would never suffice. No, all those rocks would be necessary. And not just a great pile, no, no, an intricately designed wall. Or better yet, something yet more complex: a dome formed with each rock set carefully in place. Rock against rock. Force pressing up against force. Rocks tucked tight so that the tension could somehow hold up the curvature.

To come to this day, this day seemingly like hundreds of others, has required a hundred thousand minute steps. How many times has a nurse “entered” her line? Fifteen seconds of scrub time. Fifteen seconds of dry time. How many sets of vitals? How many CBCs (Complete Blood Count)? How many echos and bone marrow biopsies? How many times have her cells gone hurtling past a laser, striking that electron off to release a burst of energy at a precise wavelength to reveal its identity? How many transfusions of red blood and platelets? How many emails flying back and forth between doctors, careful to consider all facets of her case, what will be best? What meds? What protocols? How many great hurdles overcome? How many slim possibilities made real?

When at last the time came, when at last word came that, “the cells are here,” and the room began to flood with folk, tears came quick. Tears of being just plain overwhelmedly grateful. The weight of the bounty, the absolute wonder of all that has taken place to bring us to this day. This day. This day of transplant. This day of hope, of an open door, of another gift, another opportunity to pull a weapon from the scabbard and thrust it into the heart of those cancer cells. And the faces…faces dear to us, faces with whom the most difficult possible conversations have taken place. Faces beaming with joy for having walked long segments of this road with us. And though the faces of many were not present, I saw them still. In my mind there I saw Dr. Pollard, Dr. Gardner, Dr. Tarlock, Dr. Cooper, Dr. Berstein, Dr. Law, Dr. Kemna, Dr. Hong, Dr. Albers, the faces of countless nurses, of pathologists, and lab techs, Mohammed and Bonnie. The list could go on and on. If this was a Golden Globe I’d be kicked off the stage.

And there was something so poignant about the setting. The plan had been all along to put Allistaire in the ICU for the most crucial, dangerous portions of transplant. The ICU has many more means of monitoring her heart and an array of cardiac meds that cannot be given on the Cancer Unit. Allistaire cannot be handled by standard protocols alone. Everything that happens with intense immune responses result in the potential for great fluid shifts which in turn can radically impact the heart. The first event of concern was simply receiving her cells. As with all blood products, there is always the risk of an allergic type reaction, but even more significant is the possibility of a “cytokine storm,” due to the large mis-match between Sten’s stem cells and her own body. It is like two great waves crashing into one another. This clash of contrasts can result in a cascade of immune system signally and response that can be severe enough to be fatal.

When I asked the nurse what room we would be in the ICU, my mouth dropped at her response. Forest PICU 6 room 321. The very room we spent 70 of the 80 days Allistaire was in the PICU last January through April. So as the morning turned to afternoon and the cells finally began to flow into her line, and the “Happy Transplant Day,” song was ended, and someone yelled, “Speech!” – I simply could not resist. I could not resist proclaiming the wonder that we had come full circle, that in the span of one entire year, we had returned to this very room to at long last enter this gauntlet of transplant. As I stood there before that little throng of medical staff and family, the bare white unadorned walls of this agonizingly familiar ICU room constraining, my heart was bursting, my few words fumbling to offer up a naming of gift and thanks. Thanks for each person present and not present who has so faithfully, and graciously and compassionately done their part. We have each put our head into the wind and pressed forward though relentlessly buffeted, somehow forward motion has been attained and as we look back, wow, wow, who can believe we have covered such a great distance?!

In the center of the room, a bright flash of spirit. Allistaire Kieron Anderson, a spirit whose light is like sparkling pink lemonade, giddy, curls upon curls, curls of blonde hair tinged in pink and curves of cheek and chin with light glinting out of her blue eyes. Lord, you make a crazy claim, one hard to fathom, sometimes hard to swallow, yet simultaneously gorgeous and wondrous: You know all of our days before one of them comes to be (Psalm 139:16). I have sought your face, I have yearned to walk this life held in You and one year ago, you said, “Come, follow Me, take my hand and let us walk this way, down this road leading into darkness,” as alarms blared on pumps and CT scans and echocardiograms declared disaster. I don’t know the road ahead, but as I turn, craning my neck back to look down that dark road behind me, hand gripped in Yours, I am simply in awe, in awe of the dangers and sorrows, of tears that threatened to drown and always Your hand, never letting go, and always Your Word, Your quiet voice entreating me to fix my eyes on You, on You and rest child, rest, rest in Me though all around you, you feel the ground giving way and the night presses in thick and you can’t seem to catch your breath, and the teeth flash and your whole being groans.

And startlingly, here we are, we have circled back around. The obvious question is, “Why? Why Lord? What was the point of all that? I mean really, really, did we really have to take what feels like a year-long detour through treacherous territory only to come back to where we started yet more bloodied and bruised, wounds deep?” So much lost. So much time. So much separation. So much damage. So very many tears. The lacerations and scars are easy to see yet don’t begin to reveal the depth of ravaging. What is harder still to see is the other-worldly beauty, the treasure often imperceptible. Seeds in dirt don’t look like much. Seeds sailing on winds…The Lord’s aim has never been transplant. He aims for my heart, for all hearts and sometimes in great peril and pressing darkness we are more able to see aright, to incline our ear to His voice, to have His Word made full and pulsing with life, our stiff necks bend low and we come to worship the God of creation as never before. Getting to transplant has never been hard for the Lord. To say that it has been trivial in His sight sounds callous only when I fail to set it against the enormity of His heart for me, for me a child of Adam, a child of God. But I have no doubt God smiled broad and His face beamed as we gathered in that small room and were witness to the marvel of the human body, to the tenacious brokenness of creation, to the wonders of medicine and human endeavor, and to hope, hope for a way through.

I don’t know the road ahead and there is the quiver of trepidation, knowing there are still many dangers. But on this gray January day with rain intent on saturating, my heart feels heavy and full, full with the satiation of joy and full of yearning to keep leaning in, inclining my face to the face of my God. I look at this little girl and marvel that I should be so blessed to call her daughter and to walk this road with her, to hold her sweet little hand along the way, and to incline my ear to the pleasure of her small sweet voice, a voice proclaiming dreams of a future and joy for the present, delight in simply putting color down on paper, color alongside color alongside color.

Allistaire has made it through five fractions of focal radiation to the chloromas in her sinuses, eight fractions of TBI (Total Body Irradiation), three doses of the chemotherapy Fludarabine, all in preparation, a “conditioning,” for transplant. The only direct immediate result has been fatigue and a C-Diff (Clostridium Difficule) infection due to the effects of radiation on her gut for which she is now on Flagel. On Monday, on her day of rest, Sten’s birthday, Sten received his fifth and final shot of GCSF (Granulocyte Colony Stimulating Factor). Then, in the early afternoon over the course of several hours, his blood was pulled out, and through the action of centrifugal force, the lighter weight white blood cells including CD34 stem cells, were separated out and the remaining blood returned, a process known as apherisis. In total, the goal of 5-6 million CD34 cells/kg was achieved in a mere 187ml of Sten’s blood. Sten’s blood was then processed, having both the red blood cells and platelets removed because of the antibodies Allistaire has formed against them. When that bag of orangish red blood arrived in Allistaire’s room on Transplant Day, it contained nearly 120 million CD34 stem cells within 148 ml.

Due to extreme weariness at countless plans dashed, I felt no need to explain this transplant of Allistaire’s until it actually came to fruition. So at last it is clearly time to explain what we’re doing here because truly there are so many different types of bone marrow transplants, each specially designed and chosen to fit with the uniqueness of the patient and their disease. In order to make any sense of what is happening in Allistaire’s transplant, a brief overview of bone marrow transplants seems necessary. When transplants were first developed by Dr. Donnall Thomas of Fred Hutchinson Cancer Research Center in the 1960’s and 70’s, the goal was to have the ability to use extreme doses of chemotherapy and radiation to destroy a leukemia patient’s bone marrow, the source of their cancer, and then “rescue” them by giving an infusion of another person’s bone marrow. Without this “rescue,” the obliterated marrow could never recover and the patient would die. Only later was it discovered that a key component of a bone marrow transplant’s potential to cure comes from the immunotherapy effect of Graft Versus Leukemia (GVL). More about that in a bit.

All bone marrow transplants begin with “conditioning,” which primarily attempts to eradicate any remaining cancer cells and to make way for the incoming stem cells. Patients have the highest chance of a “successful” transplant when they go into transplant in remission which is generally defined as little to no detectable disease. In Leukemia this means 5% or less disease in the marrow and ideally no extramedullary disease (cancer cells which form tumors outside of the marrow). Each transplant protocol has specific requirements regarding disease status which determines whether or not a patient will be approved to move forward with a transplant. Additionally, there are numerous conditions of health, especially regarding the major organs (heart, liver, kidneys, etc). Determining which specific transplant regimen is best for the patient requires a great deal of data gathering and consideration. All have variable elements of benefit and risk.

The two key defining components of a bone marrow transplant are the type of conditioning and the stem cell source. There are a number of different types and doses of chemotherapy which may be used in conditioning. Additionally, a patient may or may not also receive radiation as part of conditioning. Sometimes the radiation is focused only on certain areas of the body where there have been or are tumors, or only the lymph nodes may be targeted. In Allistaire’s case, she had both focal radiation and TBI (Total Body Irradiation) which sends radiation throughout the entire body. Depending on the patient’s health, they may or may not be able to endure full intensity conditioning. For older transplant patients who may not be in optimal health, “mini transplants,” were developed by Dr. Rainer Storb, also of Fred Hutch Cancer Research. In patients like Allistaire who have one or more major organ systems that have been compromised, intensity of conditioning is an enormous consideration. While Dr. Bleakley was very hesitant to give Allistaire a full-intensity conditioning transplant given the status of her heart, the extreme aggressiveness of her disease necessitated this in order to give her any chance of a cure.

The second component that distinguishes a transplant, is the stem cell source used for “rescue” after the marrow has been decimated. This might be may very favorite part of transplant. Rescue. A word conjuring up vivid, dramatic images, harrowing situations, bravery, sacrifice, love. To read specifically about about the beauty of “rescue,” as I wrote about in Allistaire’s first transplant click HERE. Originally, all transplants used whole marrow as the stem cell source which meant all donors had bone marrow removed directly from their bones. In time, a method was developed for harvesting stem cells from the peripheral blood with the aid of GCSF (Granulocyte Colony Stimulating Factor). GCSF promotes the production of stem cells in the marrow and their mobilization into the peripheral blood where they are collected by apherisis. This is the means by which Sten donated his stem cells. Lastly, the most recently developed stem cell source is that of cord blood. Cord blood is blood that is extracted from the umbilical cord of a newborn baby. Mothers can opt to donate their child’s cord blood which is then registered with the National Marrow Registry and banked, awaiting a person in need of a transplant. It should be noted that some cancer patients have their own stem cells harvested and then reinfused after conditioning. This type of transplant is known as an Autologous transplant. However, whenever a particular blood cell line itself is the source of a patient’s cancer, as in the case of leukemia, they cannot be “rescued,” with their own stem cells as these are the source of their cancer. In an Allogeneic transplant, the patient receives another person’s stem cells.

Many clinical trials have been conducted exploring the risks and benefits of diverse combinations of conditioning regimens and stem cell sources. However, a major consideration in determining what type of stem cell source to use in a patient’s transplant is simply availability. To receive someone else’s bone marrow fundamentally means you are receiving another person’s immune system. Our immune system is able to accomplish the extraordinary defense of our bodies in large part because of its ability to identify “self” and “other.” This is actually why cancer is so hard to eradicate. In essence, the immune system of a person with cancer has failed to identify their cancer cells as “other.” This is because cancer cells develop from normal healthy cells. The goal of virtually all cancer treatment is to discern and target the subtle differences between healthy cells and cancer cells. Typically a prospective transplant patient is “matched” to the greatest degree possible with the incoming stem cells so that the incoming cells look as close to “self” as possible. This is done through HLA typing. On human’s chromosome 6, there is a grouping of genes that encode for Human Leukocyte Antigens (HLA) which are then presented on the cell surface of all cells in a person’s body. It is like a bar code (in the form of cell surface proteins) used as a unique identifier for that person. These HLA proteins are what distinguish one individual person from another and are what allow a person’s immune system to identify “self” from “other.” The immune system aims to identify and destroy anything “other.” For this reason, it is essential that there be a significant degree of HLA matching between the patient and the incoming stem cells. Otherwise, the patient’s own immune system would heartily attack and destroy the incoming stem cells. When this happens it is known as “graft failure.”

Another potentially severe complication of a HLA mismatch between patient and donor is known as GVHD (Graft Versus Host Disease). In this situation, the incoming donor cells may identify the patient’s body as “other” and set about attacking the patient’s tissues, most commonly the skin, gut and liver. GVHD can even be fatal. The ways to prevent or reduce GVHD have typically been to select the highest degree of HLA matching and/or give the patient immune suppressants which suppress the immune fighting T-cells within the graft/donor cells. A major down side of immune suppressants is that they also suppress the incoming immune system’s ability to fight infection which can often lead to life-threatening infections. As research into GVHD progresses, scientists are learning more about what subsets of T-cells are responsible for the majority of GVHD. Dr. Bleakley has been conducting a clinical trial in which the “naive T-cells” are depleted or removed from the donor cells prior to infusion into the transplant patient. This has succeeded in substantially reducing the incidence of chronic GVHD. Click HERE to read more about this fascinating research yielding substantially better results.

The highest degree of HLA matching is a 10 out of 10 match, which means the patient’s cells share the same genetic code as the donor cells at the ten major points on Chromosome 6. In order to accomplish this matching, patient and donor most often share very similar ethnicity. It is more difficult to find a good match for those patients who are ethnically diverse, whose ethnicity is rarer or derives from parts of the world in which there is very low Bone Marrow Registry participation. For example, one of our friend’s was from the indigenous tribes of Guatemala. Her specific ethnicity is simply rare in the world. Another friend with sickle-cell was Ugandan, a part of the world with very little registry participation. Almost amusingly, in Allistaire’s case she may be “too white,” in that she has never had a single match within the United States. Her matched donors have always been found through the German registry. She was unable to participate in Dr. Bleakley’s naive t-cell depleted protocol because it requires a U.S. donor. For this reason, patients will have better transplant options when more people join the Bone Marrow Registry, thus increasing the likelihood that the patient can find a match. For patients who have no sufficient bone marrow matches, cord blood can be a good option because it must be matched at fewer points (max of 6 out of 6). Again, this is why donating your newborn’s cord can literally save a life!

As noted, the two major distinguishing components of a stem cell transplant are the type of conditioning and the type of stem cell source. There is no one right transplant as each patient comes into needing transplant in varying degrees of health, disease status and access to stem cell source. Allistaire went into her first stem cell transplant in June 2013 with nearly 70% disease in her marrow and 9 chloromas/tumors. Otherwise her body was “healthy.” Nevertheless, because of the enormity of her disease, she was only able to receive a transplant because of a specific transplant clinical trial through Fred Hutch that did not require remission. She would have been dead long ago had it not been for that clinical trial. When Allistaire relapsed again in October 2014 and needed a second transplant, we were aiming to use the “naive T-cell depleted transplant,” which did require remission. Fortunately remission was attained but Allistaire had no U.S. matches and Dr. Bleakley set about trying to gain permission from the FDA and the German registry to allow Allistaire to use the available matched German donor from outside the U.S.

However, last January the cumulative effect of her years of chemotherapy and the severe typhlitus infection put her into heart failure. She no longer qualified for transplant because of the extremely poor function of her heart which nearly resulted in her death. Even once she regained some function, for a very long time she would have only qualified for low-conditioning transplants. However, no low-conditioning transplant could sufficiently wipe out her extremely aggressive disease. So for the past 10-11 months the goal has been to keep her cancer under control while giving her heart the time to possibly regain enough strength to qualify for a full-intensity conditioning transplant. This has been extremely difficult as the oncologists have had limited treatment options. Many types of chemotherapy themselves can be hard on the heart and/or greatly assault the marrow, effectively suppressing the immune system which then allows for the possibility of life-threatening infections. Not only can the infection itself kill you, but the body’s attempt to fight the infection often causes major fluid shifts, changes in heart rates and blood pressures, all of which can put major strain on the heart. Even seemingly minor situations like the two instances of an ileus resulted in all her medications, fluids and sustenance being given IV which puts a great burden on the heart. It is a tough situation all around. This was the reason for trying the WT1 modified T-cells and the decision to try Mylotarg (available only on a compassionate-use basis through Fred Hutch). And while the Mylotarg was impressively effective against Allistaire’s cancer, one problem has been the incidence of cancer cells mutating in resistance to it and the risk of causing SOS (severe liver complication) in the context of transplant (which is why it was pulled by the FDA in 2010).

Once Allistaire’s heart began gaining strength as evidenced by ejection fractions (as determined by echocardiogram) in the high 30s and low 40s, the discussion began in earnest as to whether or not it might finally be time to give one more great thrust toward transplant. Countless conversations between the Oncology, Bone Marrow Transplant and Cardiology doctors debated risks and benefits which were strongly tied to both keeping her disease under control long enough to get to transplant and what transplant regimen could give Allistaire the best chance at a cure and not kill her in the process. When Dr. Bleakley first suggested the real possibility of a Haplo transplant, my gut response was to spit that idea right back out. A Haplo-identical transplant is one in which the patient is half matched (5 out of 10) with a parent or sibling.

Because of this extreme mismatch, Haplo transplants have historically been associated with many poor outcomes including graft failure, high incidence of severe GVHD, high rates of infection and relapse. Each awful complication results from attempts to respond and mitigate one of these other complications. For example, because the HLA is only half matched between patient and donor, the patient’s immune system can attack and wipe out the graft/donor immune system. Graft failure can be mitigated by increasing the intensity of conditioning to suppress the patient’s own immune system. However, there is still the likelihood of severe and/or chronic GVHD where the donor immune system attacks the patient. In order to combat this, the patient is given immune suppressants to tamp down the immune response in the donor cells. This in turn results in severely lessened ability to fight infection and may reduce the Graft Versus Leukemia effect which is the advantageous and desirable element of the mismatch between “self” and “other.” Remember that because cancer cells derive from healthy cells, they carry the HLA typing of the patient so when donor cells come into the patient’s body, they are more able to recognize the cancer cells as “other” and destroy them. Dr. Bleakley provided me with this paper, (Modern Approaches to HLA-haploidentical blood or marrow transplantation), which gives a historical overview of Haplo transplants.

Dr. Bleakley went on to describe a more recent approach to Haplo transplants which has yielded results on par with that of standard unrelated-matched donor transplants. The most unique aspect of this transplant is that the extreme mismatch between patient and donor (half-matched parent or sibling) which would naturally produce immense GVHD, is greatly mitigated by giving a strong dose of the chemotherapy, cyclophosphamide (also known as Cytoxan), on days 3 and 4 after the infusion of the donor cells (the actual day of transplant). This also occurs in the absence of any immune suppressants which are traditionally started at Day-1 (the day before transplant which is known as Day 0). What this means is that when the donor cells go into the patient’s body, there is an uproar of immune systems in which the donor immune system begins to respond to the presence of “other” by rapidly dividing its Tcells and beginning the process of fight or GVHD. There is nothing to lessen this response of the incoming donor cells because there are no immune suppressants present. This is where the possibility of a cytokine storm comes in and where severe GVHD could take off if there was no intervening. The possible cytokine storm must simply be managed as best as possible but the revving up of the donor Tcells is stopped in its tracks by these two large doses of cyclophosphamide on Day+3 and +4. The cyclophosphamide targets rapidly dividing cells including the Tcells, which left unchecked, would produce immense GVHD. The way that the whole graft/donor cells are not altogether wiped out by this chemo is that, according to a recent discovery, stem cells have proteins on their cell surfaces which make them immune to this particular chemo. Also left, are a subset of Tcells which were not highly activated and can still go on to fight infection and provide GVL (Graft Versus Leukemia). There are various versions of this “post-transplant Cy.” Allistaire’s includes TBI (Total Body Irradiation) in the conditioning portion of the transplant which is essential given the aggressiveness of her AML and the ongoing presence of extramedullary disease. Other “post-transplant Cy,” transplants may have reduced intensity conditioning. Dr. Bleakley followed a transplant regimen based on the research described in this article (Total Body Irradiation-Based Myeloblative Haploidentical Stem Cell Transplantation in Patients Without Matched Sibling Donors), published in July 2015.

So at long last we come to this week of transplant. And for those of you with eyes glazed over or simply head asleep on the keyboard, part of my motivation in going to such lengths to explain this transplant is not only for my own documentation, but also for folks out there in situations like ours who may need detailed information. Given the condition of Allistaire’s heart and the aggressiveness of her disease, we therefore, chose a transplant with full-intensity conditioning and most importantly, full dose TBI which you can only have once in a lifetime. The reason for choosing Sten as Allistaire’s donor is for three main reasons. First off, Allistaire’s chance of both surviving transplant and having it actually cure her is extremely low and so ethically, the doctors do not feel right about asking an unrelated donor to undergo risk and burden to be her donor. Secondly, given the highly fluctuating nature of Allistaire’s health and disease, the projected date of transplant could easily change which might mean we lose our donor who has constrained availability and requires more pre-planning because they would be donating on the other side of the earth (remember no U.S. donor matches). Sten, as Allistaire’s father, is more than willing to take on risk and burden and is a highly committed and extremely flexible donor. By the way, both he and I were options but it was concluded he was the better choice. Lastly, the statistics for acute and chronic GVHD, NRM (non-relapse mortality), relapse, DFS (2 year Disease Free Survival) and OS (2 year Overall Survival), were on parr with the statistics for standard unrelated-matched donor transplants. This means that we have the opportunity to give Allistaire as good of a chance at survival and a cure with her dad as a half HLA matched (haplo) donor as she would with a fully matched 10 out of 10 HLA matched unrelated donor with the added benefit that comes with having your awesome dad who is willing to literally lay down his life for you.

Thus far, Allistaire has received her infusion of Sten’s stem cells, essentially getting her transplant on Tuesday, January 12th. She had no allergic reaction to the cells. However, later in the evening she had a fever with higher heart rates. Whenever an immune suppressed patient (in her case because of conditioning, not immune suppressing medications), gets a fever, blood cultures are drawn and antibiotics are started in case the fever is evidence of an infection. Thankfully, Allistaire’s fever seems only related to her response to the mismatch of the incoming donor cells. Dr. Bleakley was quite pleased as the fever was evidence of an immune response without the danger of a full on cytokine storm.

In the last few days, Allistaire has started to get some mouth sores, an expected result of conditioning which especially impacts rapidly dividing cells. This means all the cells lining the digestive tract from the mouth all the way out the other side are hit hard. This can result in mucoscitis. She is more gaggy and nauseous, has thrown up a few time and has begun to eat far less. At this point we are prioritizing her drinking the necessary fluids and continuing to take her oral meds, (rather than giving her IV fluids and IV meds which would be harder on her heart). We are attempting to have her drink a pint of milk at each meal time to provide some calories in the form of protein and fat. She may soon require her nutrition to be converted to TPN and lipids which are essentially IV forms of sustenance.

The next storm on the horizon begins tomorrow with the two days worth of cyclophosphamide infusions. A side effect of cyclophosphamide can be bladder bleeding which they try to counteract with hyper-hydrating and a medication called Mesna. Because of Allistaire’s weaker heart, they are reducing the hydration from the standard 1.5 times maintenance to 1.25 and are hopeful that this will both be enough to prevent the bladder bleeding and not overwhelm her heart. Another serious and potentially fatal, but rare, possible side effect of cyclophosphamide is acute cardiomyopathy due to hemorrhagic myocarditis. Depending on how things go, Allistiare could be transferred from the ICU back to the Cancer Unit early next week.

Honestly, it is an absolute wonder that she ever made it to this transplant. Whether or not she will survive the transplant or it will be successful at curing her of her cancer are totally separate questions. I am just simply in awe that we are here. The Lord will continue to be faithful, morning by morning, come what may.

Each night Allistaire crawls to the head of her bead and turns off the flashing “sea urchin,” lights and tears a link from the paper chain. The chain is still eight links long, but ten have been torn away, time stripping down. Each morning my alarm goes off in the dark, despite all the mundaneness, the normalcy, I find myself a bit surprised we are still here, still doing this. I stretch out on a bed that later in the morning will fold into a couch and always marvel at how it is the most comfortable, in this one room out of three in which my life is spread out. Three bottles of contact cleaner. Three tubes of toothpaste. Bags. I live out of bags. Bags coming. Bags going. And each evening I wash the day’s dishes in the tiny white porcelain sink and am surprised to find another day ending, light gone and moon rising.

Each morning I settle into a quiet spot in Starbucks and drink my double tall, extra-hot, caramel latte and eat my bacon gouda sandwich, looking out the window, gazing but eyes not seeing, wondering, inquiring, inquisitive, curious. Marveling. What is this life? There are so many constraints, bonds, limiting factors, losses, saddnesses, pains that seep out like wounds refusing to heal. I am walled in, cut off, restrained. I saw my cross-country skis when I went home, still wrapped new in plastic from a year and a half ago. My hair shows countless wily grays, rising perpendicular from their counterparts, defiant, declaring their independence, shooting outward at odd angles, more wrinkles gathered around my eyes. Life proceeds forward with regularity, and we? We languish. We circle over and over and over, tight tiny circles, moving between two rooms: Forest Level 7 Room 219 and Ronald McDonald House A Room 362. Each afternoon we’ve left the hospital on a pass, Allistaire’s little gleeful eyes peeking out over the mask, protecting her from those who might spew viruses into the air. We move from one room to another room, two small spaces, a figure eight.

For so long we have pushed, straining forward, inertia to get to this point, this first day of transplant, the beginning of conditioning. “Transplant,” has been the metronome of our days, the ceaseless pound of that one word, the undergirding of all we do, every choice made in orientation to this one goal. And as the links have fallen away, giddiness has welled, shock and joy that at long last we are coming to the day for which we first came over fourteen months ago. We are finally about to do what we came to do. Yet in these last several days, a hush of sadness wafts down like tiny snow flakes, gathering in the cracks. An odd silence as I take in the lush curve of her cheery cheeks, made more chubby by steroids. I watch her hands fiddle with a curl, thread back through her blonde hair and I realize how short is the time left with that hair, hair that took a year to grow. I listen to her happy little voice and watch her eagerness to play, and my heart feels tender from deep bruises. Oh. Oh what are we about to do? What is about to happen to this happy little girl? As the days have slipped down to two and one, I know that she now, at long last, stands on the threshold of a momentous undertaking. “TBI (Total Body Irradiation) is like being near the epicenter of a nuclear blast.” Those words echo quiet, pinging back and forth inside my cranium. I cannot help but imagine her little naked body, covered in gray ash, devastation and annihilation radiating out around her. Always Hiroshima with my little one standing at ground zero, knowing I willingly put her there. “There is a good chance she could die in transplant.” Late effects. A broken body, devastated from all the ravaging magnitude of what is to come.

We stand at an open door.

We stand at a door we never thought would open. With this relapse there was the great fear that she would never get into remission, given that nothing even slowed her cancer before her first transplant. But remission was achieved and transplant scheduled for March. Then we watched her heart race at 187 beats a minute as her body agonized to respond to the might of her typhlitus infection. For two weeks, every other day, she received granulocyte infusions to give her body a means of defense when her own marrow, decimated from chemo, had nothing to offer up. Fevers and pain meds around the clock, tubes and wires and hoses and monitors. And at last she came out of that storm and all was peeled away and she appeared herself again, yet now with a heart tattered and weary, heaving, expanding on itself, barely able to exert the force necessary to send oxygen hurtling through all her extremities. A heart they told us, that would never recover its function. Round after round of chemo to keep the leukemia at bay, but silently cells continued to infiltrate her flesh, gathering in the open curvatures of her skull, filling and pressing out, gnawing away at bone, forcing her eye up and out. But what to give her, what will be powerful enough to fight the cancer cells and not also overwhelm her heart that so desperately needs to heal? Mylotarg. An anti-CD33 monoclonal antibody drug conjugate, withdrawn by the FDA but made available through Fred Hutch on a compassionate use protocol. Progress against the cancer but also some sort of infection in the lungs making more chemo dangerous. Another gift, an attempt at a new therapy, a meticulously designed T-cell sent on a mission to destroy all cells bearing the mark of WT1. But to no avail, no effect, no ability to slow the onslaught of those cancer cells. More Mylotarg, more gifts, more open doors. And behind it all, the compassionate hearts and brilliant minds of doctors sorting through all the details and directing the strategy. And above and below and hemmed in on all sides, the Lord is at work, closing and opening doors and carefully, meticulously, crafting all the days of these past fourteen months.

We stand at an open door, a door long prayed for, long yearned for, desperate panting, exertion on all levels to open. And open it He has. And this morning we walked through. January 4th, 2016 has come and Allistaire innocently and willingly laid her body down on a little table with a great machine overhead, a machine that would cause a beam of radiation (12 Gy in total) to hurtle through her body, tearing DNA in its path, a mindless destroyer. She will do this eight times, each time laying on her back and then flipping over onto her stomach. The first four of eight “fractions,” includes the use of lung blocks, great wedges of a combination of lead and bismuth, to reduce the impact on her lungs; one set for the front and one for the back. They are carefully set into place on a glass table that sits overtop of her and the doctor checks their placement by X-ray.

Monday through Thursday this week Allistaire will get TBI and then Friday through Sunday she will get the chemotherapy, Fludarabine. This sums up her “conditioning,” with the intent of myeloablation, a complete destruction of her bone marrow which harbors the source of her cancer and any cancer cells throughout her body. For Allistaire, Monday is a day of “rest.” This simply means that there is no treatment that day. It is a lull.

But really, Monday is a spectacularly significant day. Monday, January 11th is Sten Karl Anderson’s birthday. And what gift to give on such a day? On that day, it will in fact be Sten who is giving the gift. On January 11th, Sten will sit in a chair for two to three hours with large needles in his veins as his blood is being pulled out, blood replete with stem cells for Allistaire. On January 7th, Sten will begin five days of GCSF (Granulocyte Colony Stimulating Factor) shots which will prompt his marrow to produce hematopoietic stem cells (HSC) and mobilize them into his bloodstream. These HSCs are the stem cells that give rise to all the other blood cells in the body. On the day we celebrate the birth of his dear youngest brother, Jens Hagen Anderson, Sten will begin the process of offering another chance at life to Allistaire. There is no doubt, these days are a powerful, turbulent combination of joy and sorrow. We rejoice in Sten’s life beginning and being sustained another year. We rejoice that he has the uniquely beautiful gift of offering life to Allistaire from his own life, his own blood. And while we rejoice in the 28 years of life given to Jens and all who have been blessed to know him, we mourn that we no longer have him with us. Jens will never know 2016. We mourn that in order to give Allistaire an opportunity to live, we must first bring against her the most powerful weapons medicine has in its arsenal. We must brutally ravage her body, with the real potential for death, to give her one slim chance to live.

Sometimes, when I let myself go there, when I turn to take the brunt of the sorrows of sickness and death and sin, when I face them head on, when I look them full in the face…I feel such deep agony of pain, a tearing of the sinews, splintering of bones…it is simply too much, I must turn away. Turn away or drown, turn away or? How did Christ do it? How ever did He take on the incomprehensible weight of such brokenness? Like Moses who could not bear to look full into the holy face of God for fear of death, nor can we look fully into the black. We cry out, “Why? Why God? Why don’t you stop this agony? Why don’t you put all this wretchedness to an end?” I can tell you this, sickness and death have an incredible power of clarity to reveal how truly broken this world is. They declare to us that despite all our great intellect and all of our earnest strivings, we are not in control. This is a double-edged sword, brokenness and finiteness, but isn’t it too gift, gift that this brokenness may end, that it need not be eternal? Death is a door to the end of brokenness and sin. Death is a door that, if we kneel to Jesus Christ as God, is the means to eternal life with no more sickness, sin or death. And you and I might like to scream, with tendons of neck flexed until we go hoarse, “You have done it WRONG!” We hurl our rage and agony out into the silence, out into a night sky layered thick with stars. And the stars sing back, not with explanation, not with answers that satisfy, but with a declaration that God is God and He loves us and He has made a way for redemption and for life, and will we bow?

I dwell here, in “the already,” and the “not yet,” a time between times, a time of tension. I have begun to notice that some of my most favorite songs, songs meant for road trips, for travel, tend to have this interesting quality of two parallel elements of sound. On the surface, in the forefront, are notes of faster pace, a sort of galloping, running, small, short quicker sounds, building and waning but rising, intensifying, swelling upward. You feel the tension growing, rising higher and higher. You long for release, for resolution, for a letting up of the momentum, but at the same time it is tedious, staccato, repetitious. Below and in parallel, a tandem sound, notes drawn out long, low deep stretched wide, great sweeps of sound undergirding the frenzy above. I live in the frenzy, in the tedious, in the repetitious, in a tension that builds and longs to be released. I live in an unresolved state and I ever feel its angst, the thorn that will not be removed. And yet I listen, I incline my ear to hear that which does not as immediately demand my attention, the sounds that have always been there, the declarations that this life is undergirded. Sounds of peace, wide broad sweeps across the universe, across time, across this earth and history and ethnicity. I feel my tension relax as I harken to the sounds that declare redemption has already been accomplished. Sin and death have already been broken and done away with. Christ is seated in heaven. “It is finished,” He cried because ultimately in the cross all has been accomplished, justice and grace. We finite beings live within the constraints of time, but God is above and beyond and within time. All has been accomplished. Only because of this is it well with my soul.

Winter Solstice is passed. The darkest night of the year is behind us. Ever so slowly, at a staggering speed, we make our way back toward the sun.

I can hardly believe the earth has made an almost complete orbit around the sun since that day last January when Allistaire’s immune defenses dropped to zero and typhlitus nearly took her life and ravaged her heart, a heart already made vulnerable by so very many rounds of chemo. There have been so many very dark days, so many tears, so much uncertainty, so many occasions where all appeared bleak. And yet…I cannot begin to count the number of barriers overcome, walls knocked down, doors that opened. I stand back and I survey the road behind us, it both tires me and brings elation, joyous shock, mouth-gaping awe. The world is just as quiet and just as loud and busy and frantically running around, and I stand, I stand and look around me, and really, I cannot believe we are here.

It is a grey day. There is no snow to beautify the land, no hush of quiet, no blue light of early morning snow reflecting the sun’s advance over the horizon. The earth shows no sign that it knows what has happened, what has transpired in this place. I look back, back, back over forty-eight months, to a day when I sat in this very seat on a snowy day, back to the day I received Allistaire’s bone marrow results after her first round of chemo. A zero percent, no identifiable Acute Myeloid Leukemia. I felt such utter relief. I could never have imagined how long the road would be before me, of the nearly five hundred days in the hospital that would transpire between then and now and just how sly those cancer cells would be, ever-present, ever ominous, ever intent on dividing endlessly until they foolishly commit suicide by taking the life of their very own body.

I look back, my heart and mind touching back over those points in which I was told, she probably won’t make it, her chances are so very small, in the single digits. The weightiness of looming dark walls, the snarl of danger ever lurking, threatening to strangle. We still stand in the dark, there are still looming walls and teeth flashing in the night. And as I stand in this darkness, where there is so little light to make out the landscape before me, where the way forward is cloaked and unknown…I am smiling. I want to go up to each person I pass and say, do you know? Have you heard? Let me tell you a story, a story of a little girl, little but fierce. Let me tell you a story of terror, of heartbreak, of hope, of glee, of overcoming, of victory. For no matter what lies ahead, today is a day of victory. This day is a day of incalculable gift.

Sten and I sat with Dr. Summers as she went through paper after paper, our Data Review as it’s called. We looked at the highlighted numbers that tell of the wonders within, of kidney’s and liver, of heart and marrow, of lungs and bones, of cells and antibodies. Her marrow, so beat down by twenty-three month-long rounds of chemo, no longer produces almost any cells and yet, there is also no sign of her leukemia cells. Her sinuses still harboring tenacious leukemia cells, many wiped out, but there is a clear remaining presence of this disease. Her heart is not a normal heart, it gimps along but has made a marvelous recovery from the days ten months ago when it seemed right on the cusp of utter collapse. In short, it is clear that there is no chance to cure her of her cancer without the most intense myeloblative assault possible, and while her body has incredible vulnerabilities due to all the ways it has been injured and weakened from her treatment, it has a chance to maybe, just maybe weather this storm.

Dr. Summers went through all the steps of the harrowing process before her, and of a plan, a collaboration of the Bone Marrow doctors, the Heart Failure cardiologists and the ICU staff. This plan might look simple on paper but represents incredible teamwork on the part of these different specialties. Today is not just a victory for our family, it is something for many people to be proud of, for it has taken the tenacity and compassion, and skill and brilliance of many folk to bring us to this point. I thank in particular Dr. Marie Bleakley who has for so long been working behind the scenes to make this transplant an option for Allistaire, for Dr. Yuk Law and his wonderful team of cardiologists for constantly reconsidering Allistaire’s heart and how best to support it and build its strength, and for Dr. Todd Cooper along with Dr. Rebecca Gardner and Dr. Jessica Pollard, three incredible oncologists whose ability to straddle the research and clinical care of patients is impressive and have been directly responsible for helping to keep Allistaire’s cancer at bay for so long, enabling time for her heart to heal. It is simply a gray and rainy day here in Seattle, Washington, the silhouette of evergreens, firs and hemlocks, and the delicate outlines of maples and madronnas, dark against the sky. It is a quiet afternoon in the hospital, one day before Christmas, nothing to draw attention to how remarkable this day really is.

It has not been hard to call out to the Lord for help. The words come easy and swiftly, “Help! Hold onto me! Hear my cry! Mercy, mercy!” But today I feel oddly mute, sitting in this quiet corner of a hallway looking out at a day turning to night. What words? What words Lord can I bring before you to say thank you? I come before you empty-handed. I sit down at your feet and just shake my head, in wonder, in awe, in delight. Thank you Lord. Thank you Father, maker of the heavens and the earth and all that they contain. I can say only, You are beautiful, I stand in awe of you, and I love you Lord, you are dear to me.

There have always been two fights, parallel, interwoven, side by side. The fight of the flesh and the fight of the spirit. Today is a moment of victory. Today the door has been opened to transplant, of one more chance to eradicate the sickness within Allistaire that threatens her life. Today marks the entrance to many more walls and doors and dangers, but it also marks the only possible way forward, the only hope for Allistaire’s life. The fight of the spirit has always been that of Abraham, will I yield? Will I lay all my treasure, all my hopes for life at the feet of the Lord and say, “This life of mine, this life of my child, so bound together, they are Yours. You are God and all my days are for You to determine. I yield.” I enter the throne room of grace only because Christ has gone before me…He has gone before me that I am invited into the presence of the God of the Universe who actually loves me. I am able to yield because He has so demonstrated His love for me in this, that He sent His only begotten Son, so that whoever believes in Him will not perish but have eternal life! Perfect love drives out fear. I can walk forward into the dark without fear, because no matter the days ahead, I know there is light on the horizon. No matter the dangers, I cannot perish. And should this transplant take Allistaire’s life instead of restore it, while we will miss her desperately, she will have been made whole and free. She will live.

It is now Christmas Eve, a Christmas Eve like none I have ever known. For the first time in my life I did not select a Christmas tree and delight in decorating it with Christmas music playing in the background. I cannot think of a Christmas Eve that I have ever spent alone. But for the first time in a very long time, I did not wake up sad. We have a glimmer of hope. The door to transplant has been opened. Allistaire must make it 10 more days without getting sick or having some major issue come up in order to start the transplant process. Next Monday she will begin the first of five “fractions” of focal radiation to the tumors/chloromas in her sinuses. She will then have New Year’s Day and the weekend off before officially starting the transplant process on Monday, January 4th with TBI (Total Body Irradiation). Once you begin the actual transplant process, there is no turning back.

Ten days. In the scope of things, a short bit of time, but an enormous amount of time in which something could go wrong and this open door can go swinging shut again. But tonight I go to bed with joy curled up in my heart, joy to have been allowed to walk this far forward and hope for more open doors. Tomorrow is Christmas. Tomorrow is the day we celebrate the birth of Jesus Christ. Tomorrow is the day that changed everything. The birth of Jesus Christ, Immanuel, God with us, is the basis for our hope that no matter the road before us, there will be beauty and redemption and life.

How many times has my Father extended His arm out over the waters and invited me to walk – to step out on shifting waters, to look Him in the eye and trust Him, to put one foot in front of the other and put all my hope in Him? How many days have the winds buffeted and the sky seemed angry and black?

I wrote the words above on June 18, 2013. They continue to ring so true. I was prompted to look back at that day because Sten and I received an uncommon, hauntingly beautiful gift today. A strange message in broken English came to us from across the world. Allistaire’s bone marrow donor from her transplant in 2013 reached out to us, seeking to make yet another connection with us, this time in voice, in words, no longer disembodied. Katja. Katja. A beautiful name. I say it again and again, like savoring a morsel, I smile as I say it, gleeful, amazed, surprised, utterly delighted. This is the woman who gave of her bone marrow to my child, who saved the life of Allistaire, whose very cells have divided over and over and over and over for two and a half years to sustain my girl’s life. SHE’s REAL!!! I mean I knew that, of course she was real, is real, but somehow, to know her name, it is gift. And it is gift to have even the smallest means of bowing low before her, to show her honor, to convey my thanks, to cry big silent tears of joy and gratitude for her compassion, her generosity, her selflessness to give, to give to a stranger.

Thank you Katja.

The timing of her contacting us is interesting. I’ve actually been thinking about her, about Katja, this woman who was born in the same small span of time as myself. She and I, two women who have the great mysterious privilege of giving life to Allistaire. You see, if Allistaire is able to move forward to this second transplant, not only will all of Allistaire’s cancer cells hopefully be annihilated, so will Katja’s cells. It grieves my heart. I will mourn the death of those life-giving cells, those cells, those bits of Katja that have done so much for Allistaire – those cells that have protected her from bleeding out by making platelets and the white blood cells to fight infection and those most precious red blood cells who carry oxygen throughout her flesh. I will be cheering on the radiation and the chemotherapy and praying for their utter conquest of her marrow and yet, just as with her first transplant, there will also be loss, also be grieving.

The way forward is still unknown, but millimeter by millimeter we take ground. The week seemed to begin on Tuesday with her brain MRI. Later in the afternoon we were in clinic so she could get platelets and I was eager to hear from Dr. Cooper, hoping to hear that the chloromas were vastly reduced yet again and she was considered in a good position to move forward with transplant. Allistaire was busy with the Childlife Specialists, Callie and Jen, pressing her inked hands against great glass orbs. Having watched Lilly’s hands being placed against those same glass ornaments, I asked Callie to help us with this now, to preserve a bit of Allistaire, for the possible times ahead when it may seem hard to believe she ever existed, when memories of her could blur and fade. It was a uniquely painful and bittersweet moment, watching her joy at doing crafts and yet knowing in my heart why this was happening, knowing what very well may come true. It was in the midst of her cheerful chatter with Callie and Jen that Dr. Cooper came to the door. “Is it good? Just tell me…” He raises his shoulders and lets them slump back down.

The two chloromas in her sinus maxillary on the right and left have decreased both in dimension and bulk but there is a small new 1 X .8 cm chloroma on the right side. All of a sudden, when I least expected it, I yet again had the wind knocked out of me. I shake my head in bafflement, only sort of hearing as Dr. Cooper voices the possibility that this could take the option of transplant off the table. “This could be considered progressive disease…” But, but, but this is the nature of chloromas. This is exactly the sort of disease she’s had for the past three years. But, but, but…I called Sten trying to explain this news, gasping at the thought of there being nothing left. I mean, there are other trials, but we can’t just keep doing this forever. An internal conflict insures, the question of how far do you push, just how far do you go? Is stopping giving up? Lord have mercy. And what does it look like to have mercy? Is mercy finding a way forward, a tiny crack in the granite for the water to seep through? Is mercy a closed-door, a ceasing from struggle? But how? Ever how? How do I take this girl home to die and what would death look like? Because I know I don’t want it to look like those chloromas taking over her face, stealing her away right in front of me, agonizing pain. Oh God, Oh God, I’m going down and all the world blurs with tears and the scaffolding of my flesh feels like it’s giving way. Just don’t give her red blood I think, my breath quick, she’ll just get tired, she’ll just sleep. Yes, that seems the best way, I think, and I walk back to the room, to the room where my fluffy-haired, bright blue-eyed girl smiles her cooky little grin.

My alarm goes off. It’s Thursday morning and I lie eyes wide in the dark, a heaviness on my chest. Oh God. Oh God, what will this day hold? I think of those nights when I would go to bed crying, wake up crying, having to find a way to just will my legs out of the bed, to force my feet upon the floor, to rise and begin and face whatever might come my way. A luxury car commercial playing recently, quotes what is often credited to Abraham Lincoln, “The best way to predict the future, is to create it.” Hah! I laugh a sad weak laugh. Wouldn’t that be nice? It has become abundantly clear how little I can do to create the future I long for. The Christmas songs, taunt and ask, “All I Want for Christmas…” I cry in the store as the song cheerfully plays on. All I want for Christmas? All I want is for my little girl to live, to not die, to not be ravaged and stolen away.

In the dark, I walk through the room to the shower, careful to be quiet and not wake Allistaire who is ever no less than 10 feet from me. I pray, ineloquent, little fits of words, bits and bursts as I rinse out the shampoo, seeking the Lord, turning toward Him, longing to align my heart with His. In weakness and fatigue, falling before Him, not crawling and quaking in fear, but fear of the Lord, a fear that says, Yes, Yes, you are God and I am not. You are God and you are my dwelling place, you invite me into the shelter of your wing. I am weary, I am frail and broken and you draw me to Yourself, you entreat me to come, and I have no strength to walk and somehow my Jesus comes and carries me to the throne and I say, You, You are God and I am not. That is the sum of my prayers. You Oh God have created the future, all of it, the past, the present, the future. You know what this day holds and it is all swept up into the beauty of what you are creating. In You, and You alone I trust most high God, who has come down low to me. You have demonstrated Your grace, Your compassion, Your tenderness and I rest. You are the place, the person in whom I choose to trust. You know this day, Lord, I do not. It is your day Lord. She is your child God. Oh Lord, do not let me go.

My heart slowed as I saw that Dr. Bleakley would be joining our meeting, The Arrival Conference, with Dr. Laurie Burroughs leading our time. Did her presence mean it was all over? Was she here to help convey the hard words that they had decided not to allow Allistaire this transplant because of the new chloroma? It soon became clear that we were marching forward, that this chloroma had in fact caused them to push forward the process to begin the conditioning a week earlier. Dr. Bleakley was there to provide continuity. Dr. Bleakley said that prior to getting these most recent MRI results, she was still considering whether or not a reduced intensity conditioning transplant might be better for Allistaire, given her heart. She said that this chloroma had made it clear that nothing less than the full force of all they could throw at her had even a chance of ridding her of this disease.

“You know Jai, most transplant centers would not do this transplant. There are doctors on our service that do not think we should do it. There are parents who would choose not to.” The night before I had read through the protocol for the transplant and all the details of what could go wrong, of side effects. There were of course the usual side effects – nausea, vomiting, temporary hair loss, fatigue, weakness/loss of strength, fever, loss of appetite, diarrhea, increased risk of infection. But then,words taking up no more space than the others, yet whose weight left me gasping – sterility, brain injury, kidney failure, liver failure, heart failure, multi-organ failure, death. Death.

“[Your child] has been diagnosed as having a fatal malignant disease that does not respond to conventional therapy. Although remission may be able to be obtained for some length of time in a few cases, relapse will most likely occur after a short while.”

Those two faces, faces of two women I have come to know over the years, women in whom I have placed my trust, women who are brilliant, women with compassionate hearts, they tell me “not only is there a chance Allistaire could die in transplant, but there is a very good chance that she will die in transplant…Are you sure you want to do this?”

It feels as if I have always known this, as though all my life I have known about bone marrow transplants and the reality that they are brutal on the body and can kill in an effort to cure. My heart pauses, looking out over the distance, looking out to the horizon, heart heavy and I say, “Yes.” Yes, because we know what will come for her if we don’t try this. There is nothing left. We have at long last come down to this last great undertaking. I had an image in my mind the other day of Allistaire grown, crying and angry, demanding to know why I had not just let her die. I was driving east, away from Seattle, to stand witness at Lilly’s memorial, to extend my hand and heart in solidarity with Heather. Sometimes I look at Allistaire and it seems impossible to me that she has cancer. Does she really have something inside her that will rapidly kill her were it not for the enormity of this intervening? But she looks so alive. But I love her too much. But she is just unfurling all the more, day after day, new delights in coming to know who she is, who she will become. But, but…but all my love and all my yearning for her, all my delight of looking into her eyes and hearing her voice, it is not enough, I can not stop what will be.

Yes. Yes, I understand the risks. Sten and I choose to walk forward, knowing it is entirely possible that we are entering into the last weeks with her. I have to stop myself from thinking it every time I look at her, every time I delight in the sweet curve of her cheeks, the swoop of her nose, her hilarious mannerisms, her perpetual coloring of rainbows and inability not to dance at even the hint of music, of her constant tip-toe walking, her goofy laugh, her tender face that tells me, I love you mommy. I just feel my whole heart shattering in sorrow, my esophagus tightening, threading to cut off my breath. Every joy feels like a double-edged sword, every joy a cutting, the threat of severing. Somehow God just help me to live out this day, to take joy in this day and not let the possibility of tomorrow’s sorrow steal away today.

We left SCCA (Seattle Cancer Care Alliance) Thursday afternoon with the plan to go to clinic at Seattle Children’s later that day in anticipation of her bone marrow test on Friday that would also include a LP (Lumbar Puncture) to test for leukemia in her spinal fluid and Intrathecal Chemo (chemo that goes directly into her spinal cord). But upon entering our room at Ron Don she felt warm and with dread I took her temperature. 101.6 degrees, a clear-cut fever. Along with the fever, there was a strange rash of red spots on her arms and legs. And in a flash any remaining days at Ron Don were swept away. We went to the ER where blood cultures were drawn and antibiotics started. The next day a bloodstream bacterial infection was confirmed, eventually the bacteria being pinned down to a common bacteria on human skin, Staphylococcus Epidermidis. Vancomycin was started and eventually, Vanco-locks as well, which means the nurse inserts vancomycin directly into each of the two lumens of her Hickman Catheter and allows it to sit for eight hours at a time with the goal of ridding the actual plastic tubing of the bacteria, given it’s propensity to grow on such material.

Fortunately, the mysterious red spots went away and she has had no further fevers. She’s feeling great and doing well despite now being stuck in the hospital. We have a sweet room, Forest A Level 7 room 219, a room that looks out over the western end of Lake Washington, that allows a view of the sunset and the Space Needle. If all goes well, she will be in this room for the next few months, with the earliest departure being sometime in February. If all goes well, she will begin focal radiation to the chloromas in her sinuses on Monday, December 28th and continue through the 31st. TBI, which is considered the first segment of conditioning, would begin on Monday, January 4th and wrap up the two-a-day sessions on the 7th. Next would come the chemotherapy, Fludarabine, for three days. A “day of rest,” and then the actual transplant/infusion of donor cells on Tuesday, January 12th.

This all feels so far off and yet it is coming in fast, just as I want the days to slow that I might savor. She has to remain in the hospital the next two weeks in order to complete this course of Vancomycin which ends up coinciding with beginning the actual transplant process. The upside to being in the hospital is that we are able to start tackling the tests and tasks that remain to get her ready for transplant. Three major tests have already been completed: the brain MRI, the bone marrow biopsy and aspirate and the chest CT. The chest CT yesterday showed that the COP (Cryptogenic Organizing Pneumonia) in her lungs has improved, with one spot being completely gone and the others reducing in size. This is a huge relief, as the requirement to move forward was stable or improved disease in her lungs. We should get bone marrow results by the end of tomorrow or Tuesday at the latest.

Tomorrow is a very, very big day. Tomorrow Allistaire will have an echocardiogram and EKG, which feels like her biggest hurdle. The doctors again want to see stable cardiac function. While her BNP (measure of heart distress) had gone down from about 800 to the low 400s, it jumped back up as seen on Saturday morning’s labs. Dr. Kemna explained that a small change in the body and/or heart can produce a relatively big change in the value of the BNP. Dr. Kemna thought Allistaire looked great when she examined her on Saturday and was delighted to report she felt very warm and well profused. So we shall see soon enough. Tomorrow Allistaire will also have a nasal swab, nasal flush and a rectal swab all to test for a variety of viruses. Some of the tests would block her from moving forward and others would simply be for the sake of information gathering. She will also see the dentist to get a baseline of her oral health. Sarah, the physical therapist, will do an evaluation of her range of motion as this can be impacted by the transplant process of being in the hospital and by GVHD (Graft Versus Host Disease).

Thank you to so many of you who have continued to walk faithfully with us on this long road. Thank you for you for prayers and encouragement and Starbucks cards and meals and just for caring, for remembering us.

Tonight our little family of four dwells under three separate roofs. Solveig may never see her sister again. Nobody wants me to say this out loud, nobody can bear to hear those words. I have to live the realistic possibility of those words. I don’t know how many days I have left with Allistaire. But then again, I have never ever known that. I cannot predict the future. But I rest in the One who has created it. Father, oh Father, have mercy, have mercy, mercy according to your perfect love and perfect wisdom.

If you would like to offer the amazing gift of life to someone as Katja did for Allistaire, sign up to be a bone marrow donor HERE